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How Good is Your Walk Around?

(Photo and story excerpts courtesy of GASIL 2/98, The CAA Accident Prevention Leaflet).

After a very thorough pre-flight, the right seat pilot removed his jacket as he stood on the wing, secured some equipment in the aircraft and sat in his seat…OOPS. The happy crew taxied for departure and, after the power checks were done, took off. At a height of about 20 ft., the aircraft suddenly developed a severe nose-down attitude accompanied by significant buffeting that could be felt through the control column. Air traffic control (ATC) was advised and an immediate return was made. Flaps were selected gradually, and they improved the handling of the aircraft. After touchdown, ATC advised they could see a coat or a sack wrapped around the right-hand elevator. It was, of course, the co-pilot’s jacket that was draped across the tail. The pilot said the weight on the control column was immense, and control was difficult even in gentle turns. The UK Civil Aviation Authority commented that an HS 748 crashed after a door became detached and lodged on the tailplane, and said that an aircraft tailplane is very sensitive to disturbed airflow of any sort, including that produced by the accumulation of ice or even frost.

Take Five...for Safety - Fuel Drum Etiquette

This "Take-Five" is based on an article originally published in Aviation Safety Vortex 5/90, and is in response to a Safety in Air Taxi Operations (SATOPS) recommendation to publish information for pilots and aircraft maintenance engineers (AME) on proper fueling practices from fuel caches. While it was written mainly for helicopter pilots, fixed-wing operators who use fuel from drums can also benefit from the information. These "rules of etiquette" to be observed when refuelling aircraft were provided by reader John Lederman of Vancouver Island Helicopters. A new season will soon be upon us, with many a drum to be rolled! You are therefore encouraged to read this article, tear it out, and keep it handy! - Ed.

Prior to the first takeoff, make sure that the aircraft tool box contains rubber gloves, a bung wrench, filters, a standpipe and collar, a diaphragm and nylon valve repair kit, grounding cables, and enough tools to do the job. Make sure that you know how to use them.

Okay. You have just landed at a fuel cache, perhaps one that is not familiar to you. All things being equal, the fuel cell in your aircraft is presently uncontaminated, and the trick is to refuel, without incident, while maintaining this uncontaminated state!

The Basics

  1. Ensure that the drum you are using contains the proper fuel, regardless of what is printed on the outside! Also note: different oil companies have different colours for drums, but a drum's colour is not a foolproof indicator. Confirm by the appearance and odour of the fuel each time.
  2. Be suspicious of any drum that seems light or heavy: water weighs 20% more, and AvGas 10% less, than Jet B. Whatever is printed on the drum cannot be trusted if the original seal is broken or missing.
  3. Somewhere on the drum is a fill date. Most oil companies discourage using fuel that is more than two-years old. One reason is that a nasty fungus can thrive in small amounts of water in jet fuel, and will clog fuel lines. Older fuel can be used safely with caution. Check for any strange odour, or a dark or cloudy condition. If you have any doubt, do not use it.
  4. Check all unsealed drums for an "X" marked on the end. This is the accepted marking for contamination. However, the lack of an "X" is no guarantee of quality! Many pilots who use a part drum will mark the date near the bung. (If you have any doubt, don't use it!)
  5. Store the drum in the proper manner, and be suspicious of any drum not so stored, especially if you have reason to doubt whether it has been well resealed (bung or vent loose; gaskets torn, missing, or twisted). Even when properly resealed and stored, a part drum is more likely to contain moisture because of the increased "breathing" (more air content equals greater compressibility.)
  6. All fuel drums should be stored on their side, with bungs and vents at the three o'clock and nine o'clock positions. Make sure that the top of the drum (with the openings) is lower than the bottom. This will minimize breathing (air and moisture exchange from the outside).
  7. When opening a drum, observe the following:
    • Stand the drum on end and block it with the high side at 12 o'clock, the bung at 3 o'clock, and the vent at 9 o'clock. This prevents water or dirty fuel from reaching the openings.
    • Ensure that the standpipe cannot reach the lowest point in the drum. Thus, any small amount of water or dirt will remain in the drum. You should not need the last gallon badly enough to risk using it.
    • If possible, stand up your drums two days ahead of usage. This will allow contaminants time to settle out. Avoid agitating the drums when refuelling.
  8. If you have a helicopter and you must hot-refuel, avoid putting loose items such as bungs and wrenches on top of the drum.
  9. Note: Hot refuelling from drums should be done only during an emergency, or under very controlled conditions (lots of ground crew, no passengers on board, pilot at the controls, and a developed refuelling procedure complete with individual duties and signals). The potential for disaster normally outweighs the potential for time saved.

  10. Upon emptying the drum, locate it (with bung and vent reinstalled) so that it will not become a rolling or flying hazard to yourself or others using the fuel dump.
  11. Proper grounding is critical, especially during winter operations. Dry winter air and blowing snow transform the rotors into powerful static generators. Moreover, snow insulates, and static may not dissipate on touchdown. Avoid wearing nylon clothing or wiping plexiglass when refuelling. Dusty or sandy conditions are also conducive to static buildup. Check the condition of the ground cables, and replace any doubtful connections.
  12. Note: The proper sequence for grounding is: drum to ground (anchor post), drum to pump, pump to aircraft, nozzle to aircraft, then open cap. When finished, reverse order.

  13. Fuel caches should be located clear of sandy, dusty, or debris-strewn areas. They should be organized to expedite refuelling, with a good approach/departure path. (Remember: you will be heavier leaving than arriving.)
  14. Always carry and use "Colour Cut" waterfinding paste. A tube will fit unobtrusively in your map case and last for a long time. A dab on the end of the standpipe will give a positive indication of water.
  15. Ensure that the pump is equipped with a clean and serviceable go-no-go filter and particle filter in series, with intact o-rings. The go-no-go is designed to bind up and prevent flow in the presence of water. Increased pressure usually means blockage or contamination. Observe the sight glass for dirt or water in the sediment filter.
  16. Squirt the first pump strokes into a container before putting the nozzle into the aircraft. Any dirt downstream of the filters will be flushed out of the hose, and can thus be examined.
  17. Dispose of plastic caps, metal rings, and date tags from your used drums carefully to prevent the risk of foreign object damage (FOD) in the refuelling area.
  18. Don't forget that the first preflight of the day should include a draining and catching of the aircraft's sump/airframe fuel-filter contents. Do this before disturbing the aircraft.

Understanding Night VFR and the CFIT Risk

On October 30, 1997, a Piper PA-34-200T Seneca departed Fort McMurray, Alberta, on a 62-NM charter flight to La Loche, Saskatchewan, with one pilot and five passengers on board. The aircraft departed at 17:50, and was expected back in Fort McMurray at 19:30. The pilot filed a visual flight rules (VFR) flight plan, and when the aircraft did not return, the Fort McMurray flight service station (FSS) operator initiated a radio search that was not successful. After the FSS contacted the operator, an airborne search party organized by the operator departed from Fort McMurray, but could not find the aircraft. Another search was organized using military resources and the wreckage was located on the afternoon of the following day. Three surviving passengers were taken by military aircraft to La Loche and then to Fort McMurray, with serious injuries. The aircraft was destroyed by impact forces and a post-crash fire. This summary is based on Transportation Safety Board (TSB) Final Report A97C0215.

The report states that the passengers were anxious to complete the trip in order to facilitate an appointment the following day. The pilot called the FSS to check the weather at Fort McMurray and Buffalo Narrows, and filed a visual flight rules (VFR) flight plan. The pilot consulted another company pilot who had returned from a flight to La Loche at 15:00, and was advised that the cloud ceiling was about 500 ft. above ground level (AGL) at La Loche and as low as 200 ft. AGL in some areas along the west shore of La Loche lake. On his last contact with the Fort McMurray FSS after departure, the pilot advised that he had departed the control zone to the east. A passenger reported that the aircraft was flying below the cloud at a low altitude shortly before the crash.

The wreckage was found at an elevation of about 1540 ft., and had struck the tops of poplar trees at an elevation of about 1600 ft. in a shallow descent, with a right bank angle of 10 to 15 degrees. The aircraft was on course, with the landing gear and flaps retracted, when it struck the trees. The shallow angle of the aircraft’s impact with terrain, and the speed of the aircraft at impact are consistent with controlled flight into terrain (CFIT).

An examination of the wreckage indicated that both engines were developing power at the time of impact, and no evidence of a pre-crash malfunction was found. The emergency locator transmitter (ELT) was destroyed in the crash and did not activate. The pilot was one of the more experienced company pilots. He had reportedly completed a pilot decision making (PDM) course, and was described as proficient and safety-conscious.

The weather at Fort McMurray at 18:00 included a ragged overcast cloud ceiling at 1000 ft. AGL. The terminal area forecast for Fort McMurray from 16:00 to 22:00 was as follows: winds 120 degrees at 8 kt., visibility greater than 6 SM, and an overcast ceiling at 1000 ft. AGL, with a temporary fluctuation of the visibility down to 4 SM and a temporary fluctuation of the ceiling down to 500 ft. AGL. The area forecast included the possibility of light to moderate icing in cloud.

La Loche is not served by an official weather reporting agency. However, pilots reported that at the time of the accident, La Loche was experiencing overcast cloud ceilings of about 500 ft. AGL and that ceilings were lower over the higher ground west of La Loche, in the direction of Fort McMurray. Although the pilot was qualified to complete the flight under instrument flight rules (IFR), the aircraft was not equipped for IFR flight under the prevailing conditions.

At the time of departure, the cloud ceiling met the requirements for night VFR flight in the Fort McMurray area. As the flight progressed toward La Loche, the cloud ceiling decreased below the minimum required for commercial air operations. Flight below the cloud left the pilot with reduced terrain clearance and increased the requirement for effective manoeuvring to avoid collision with terrain.

The lighting conditions on departure were likely sufficient to allow the pilot to maintain a visual reference to the ground. As the flight progressed, however, the available lighting and ground reference progressively decreased. The overcast sky, the decreasing sky illumination, and the dark colour of the forested area along the route and in the area of the accident yielded little light with which the pilot could manoeuver and navigate with reference to the ground.

The aircraft was not equipped with propeller or airframe de-ice or anti-ice devices. Such devices are required by regulation for an aircraft operating in known icing conditions. Section 602.115 of the Canadian Aviation Regulations (CARs) provides that night VFR flight requires a visibility of three miles; no minimum altitude is specified. However, section 703.27 of the CARs stipulates that an operator of an air transport service flying at night must maintain an obstacle clearance height of 1000 ft. AGL. Commercial night VFR flight must be conducted on a route, and air operators are required to maintain a record of company routes. The accident aircraft was reportedly not equipped with a route manual, nor was a route manual found at the operator’s base after the accident. Other pilots employed by the operator were not familiar with the obstacle clearance requirement found in the CARs, nor with the requirements of a route for night VFR flight.

Although the operator’s Flight Operations Manual (FOM) has detailed information on day VFR flight standards, the section on night VFR contains little guidance. The requirement for the minimum obstacle clearance height is not contained in the company operations exam, and the level of pilot awareness of the requirement within the company indicates that the pilots were not receiving the information from other sources.

Although it was not established whether the pilot was subject to pressures from the passengers, customer and self-induced pressures were encountered frequently by company pilots in their dealings with other customers. As well, the occurrence aircraft was already loaded with the passengers’ baggage prior to the pilot’s return from his previous flight, and a company pilot had recently successfully completed a flight from La Loche. It is not known to what extent the pilot’s decision to depart was influenced by one or more of these factors.

Among its findings, the TSB determined that the weather at departure from Fort McMurray was within allowable limits for night VFR flight; however, as the flight progressed toward La Loche, the cloud ceiling decreased below allowable limits for a commercial air operator, and the available lighting and ground reference available en route and at the time of the accident decreased markedly from that prevailing on departure.

The TSB also determined that the operator’s FOM contained little guidance to pilots on the subject of night VFR operations, and that company pilots were subject to customer and self-induced pressures from time to time to complete flights in adverse conditions.

The TSB concluded that the pilot continued flight into adverse weather and lighting conditions that did not enable him to avoid collision with terrain. Contributing factors to this occurrence were the aircraft’s unserviceability for single pilot IFR flight and the lack of guidance to company pilots as to weather limits for night VFR flight.

As a result of this accident, the TSB sent two aviation safety advisories to Transport Canada (TC) on night VFR requirements and night VFR routes in uncontrolled airspace, suggesting that (1) TC may wish to consider disseminating applicable information to operators; and (2) TC ensure this information is included in company operations manuals.

In addition to publishing this article, TC has also issued a Commercial and Business Aviation Advisory Circular to bring attention to the situation and ensure that company operations manuals contain all required information.

Don't Try This at Home

Artist's impression of impact.

The following occurrence exposes traditional and, unfortunately, often-repeated pilot errors: non-compliance, poor judgment and decision making, lack of crew resource management (CRM) and communication, and poor pilot technique. This synopsis is based on Transportation Safety Board of Canada (TSB) Final Report A97A0078.

Damage to the right-wing leading edge.

On April 15, 1997, a de Havilland DHC-6-300 Twin Otter departed St. Anthony, Newfoundland, on a visual flight rules (VFR) flight to Mary’s Harbour with 2 pilots and 12 passengers on board. The aircraft was flown under an overcast cloud layer along the Labrador coast when, about 10 mi. from Mary’s Harbour, the cloud base lowered and the crew realized that they would not be able to maintain VFR. They climbed to 2000 ft. above sea level (ASL), and then proceeded direct to the YMH nondirectional beacon (NDB) in instrument meteorological conditions (IMC). After crossing the YMH NDB, the captain flew a racetrack pattern for the NDB A circling approach, a company approach not published in the Canada Air Pilot.

The crew stated that one to two miles short of the NDB, the aircraft broke out of cloud at minimums and they could see the airport. They turned right, flew downwind, and entered a descending left turn to land on Runway 11. Just short of the threshold, at about 50 ft. above the ground, the captain realized that he could not position the aircraft for a safe landing, so he initiated a missed approach. He applied full power, selected flaps up to 10°, and levelled the wings. The aircraft crossed the threshold of Runway 11 on a heading of about 130°M and, unbeknownst to the crew, the right wing struck a tree off the right side of the runway. The captain continued eastward, joined the circuit for Runway 29, and landed safely. The crew discovered the damage to the aircraft while taxiing to the ramp. None of the crew and passengers was injured.

The captain and first officer had flown together previously but neither had received CRM training; the captain had received pilot decision-making (PDM) training five years prior to the occurrence, and the first officer did so three years prior to the occurrence.

St. Anthony is a sub-base for the company, and flight crews based there have no direct supervision and operate on a pilot self-dispatch system. Other than the annual mandatory check rides, the company does not perform periodic audits of the pilots’ operating standards or route checks, nor is it required to do so. The tree was about 20 ft. tall, located about 95 ft. to the right of the right edge of Runway 11 and 1200 ft. from the threshold. The tree was broken off 8 ft. 6 in. AGL, and it appears as though the wing struck it at that point. With the aircraft parked on level ground, the wing tip is about 11 ft. 6 in. above the ground. Damage consisted of an 18-in. tear running aft from the leading edge of the wing, 46 in. inboard from the wing tip, with damage to the internal wing structure and the de-icer boot.

Mary’s Harbour airport is uncontrolled and in uncontrolled airspace. The YMH NDB is a private NDB, and the only Transport Canada approved approach to the airport was the operator’s NDB A approach. There is a note on the approach chart stating that circling is not authorized north of Runway 11-29." Most of the airports along the Labrador coast are equipped for NDB approaches only and, generally, the instrument approach minimums at these airports are higher than VFR minimums. Therefore, flight crews will try to maintain VFR while flying between these airports in order to increase their chances of landing and completing their scheduled flights. The captain checked the en-route and destination weather before departing St. Anthony and determined that they would be able to get to Mary’s Harbour VFR. A VFR flight plan was filed but, because of marginal weather conditions in St. Anthony, a special VFR clearance for departure was required.

Standard operating procedures (SOP) had been developed by the company prior to the occurrence, but they had not been implemented into the company operations. SOPs ensure procedural uniformity and facilitate communication between crew members on issues such as changes to aircraft configuration and performance. Neither the captain nor the first officer communicated any altitude or descent information during the circuit procedure. Also, no communication took place regarding power settings, flap position, and proximity to the ground after the captain called for the overshoot.

Successful landings are normally preceded by a stabilized approach, where an aircraft has a constant rate of descent along the selected approach path; an appropriate, stable airspeed; a stable power setting; and is configured for landing. Both the captain and first officer stated that during the initial part of the overshoot the aircraft was flown at its best single-engine climb speed of 82 kt. with both engines set at maximum available power, propellers full fine, and the flaps at 10°.

The Flight Operations Manual cautions pilots that "In a go-around with flaps extended, the nose of the aircraft will point below the actual flight path." The stall speed with the wings level, flaps 10°, and an aircraft weight of about 12,000 lb. was calculated to be about 65 kt. Some of the passengers commented that they heard an alarm or warning horn during the latter stages of the approach and during the overshoot. The only sound that is similar to the passengers’ descriptions is the stall warning horn, which activates when the aircraft is approaching an aerodynamic stall.

Performance charts indicate that, with the flaps set at 10° and at an indicated airspeed of 78 kt., the aircraft should have been able to climb at about 1500 fpm at a climb gradient of about 0.18. The climb calculations assume take-off power, propeller rpm 96%, intake deflectors retracted, and no wind.

The report states that when he could no longer fly safely below the cloud, the captain elected to enter cloud, without filing an instrument flight rules (IFR) flight plan, and continue to Mary’s Harbour. When the aircraft broke out of the cloud prior to reaching the YMH NDB on the approach, the captain was faced with options. One option was to discontinue the instrument approach and join the circuit for a normal VFR landing. The other option was to complete the approach and land in accordance with the company NDB A, in which case circling north of the runway was not authorized. The captain’s course of action was not in accordance with either of these approved procedures.

When the crew saw the airport, there was adequate space to turn onto downwind and complete the circuit, but the captain did not adequately consider and compensate for the wind (027°M), which drifted the aircraft toward the runway during and after the turn onto downwind. During the turn onto base leg, the tail-wind component increased, which increased the aircraft’s ground speed. The result was that the aircraft was never established on a stabilized approach to the runway nor was it aligned with the runway down to as low as 50 ft. AGL.

The decision to overshoot was made when the aircraft was over the threshold of the runway, about 20° off the runway heading and at an altitude of about 50 ft. AGL. This decision was made too late and the procedure used was not aggressive enough to ensure obstacle clearance. A slow application of power, a settling of the aircraft when the flaps were raised, possible wind gusts, poor visual cues and pilot technique are possible reasons the aircraft did not climb immediately when the missed approach was commenced.

The TSB determined that the captain, in view of the wind and weather, did not adequately plan the last portion of the flight, and, as a result, he was not able to position the aircraft for a safe landing. He then delayed initiating the missed approach until it was nearly impossible to recover safely, although there must have been early indications that the final turn was not going to be successful. Then, given that the aircraft was very close to the ground when the captain initiated the missed approach, he did not fly aggressively enough to ensure that all obstacles in the flight path would be cleared.

In reviewing this article, the training folks here at Transport Canada commented that the development of an integrated program of commercial pilot training has identified a need to develop more pilot skills in handling circuits at lower, but still safe, levels. This type of training will be useful in getting pilots to be more proficient in handling IFR-to-VFR transitions, circling manoeuvers and other low-level VFR manoeuvering near the aerodrome.

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