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The Suspension or Cancellation of Canadian Aviation Documents Due to “Incompetence”

by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada

Previous issues of the ASL have contained articles that described the recently published staff instructions SUR-014, 015 and 016—the Transport Canada Civil Aviation (TCCA) internal guidance material related to the suspension or cancellation of a Canadian aviation document (CAD) or revocation of managerial positions approved by the Minister. The first article introduced these TCCA staff instructions, and indicated that future articles would delve further into the legal authorities that the Minister has for “certificate action”, i.e., the suspension or cancelation of CADs, such as licences or certificates. The second article in this series detailed the suspension of a CAD under the authority of section 7.(1) of the Aeronautics Act (the Act), which enables a TCCA inspector to respond to an “immediate threat to aviation safety”. This article will focus on the Minister’s authority to take certificate action when “the holder of the document is incompetent.”

Section 7.1(1) of the Act specifies that the Minister may take certificate action for safety reasons other than a situation that poses an immediate threat to aviation safety. The three reasons are listed in paragraphs 7.1(1)(a), (b) and (c) of the Act:

  1. the holder of the document is incompetent;
  2. the holder or any aircraft, airport or other facility in respect of which the document was issued ceases to meet the qualifications necessary for the issuance of the document or to fulfil the conditions subject to which the document was issued; or
  3. the Minister is of the opinion that the public interest and, in particular, the aviation record of the holder of the document or of any principal of the holder, as defined in regulations...warrant it.

The meaning of “incompetent”—in terms of paragraph 7.1(1)(a) of the Act—is a fundamental concept that must be clearly understood. This key term is not specifically defined in the Act or in the Canadian Aviation Regulations (CARs). For guidance, we can consider dictionary definitions, as well as past determinations of the Transportation Appeal Tribunal of Canada (TATC).

The Concise Oxford Dictionary, Eighth Edition, defines “incompetent” as:

  • not qualified or able to perform a particular task or function
  • showing a lack of skill
  • not able to perform its function.1

The definition for “incompetent” in Merriam Webster’s Collegiate Dictionary, Tenth Edition, includes:

  • inadequate to or unsuitable for a particular purpose
  • lacking the qualities needed for effective action
  • unable to function properly”.2

In this context, “incompetence” refers to the inability to perform required activities. Therefore, it is an inability to comply rather than an unwillingness to comply.

The TATC3 has previously rendered decisions on the concept of “incompetence” and has adhered to a set of principles that were enumerated in Mason v. The Registered Nurses’ Association of British Columbia:

  1. The particular definition placed upon the word ‘incompetency’ should be molded by the object of the enactment in which the word appears.
  2. All the definitions of ‘incompetency’ focus on the lack of ability, capacity or fitness for a particular purpose.
  3. The want of capacity, ability or fitness may arise from a lack of physical or mental attributes. However, a person not lacking in physical or mental attributes may nonetheless be incompetent by reason of a deficiency of disposition to use his or her abilities and experience properly.
  4. Negligence and incompetence are not interchangeable terms. A competent person may sometimes be negligent without being incompetent. However, habitual negligence may amount to incompetence.
  5. A single act of negligence unaccompanied by circumstances tending to show incompetency will not of itself amount to incompetence.4

The TATC has also further amplified the first principle: “The object of the enactment in which incompetence appears (i.e., Aeronautics Act) is aviation safety.”5

Evidence that collectively demonstrates an inability to comply with the regulations and standards, over a reasonably lengthy period of time, demonstrates a state of incompetence; one or two incidents do not constitute sufficient grounds to substantiate incompetence. The evidence used by the Minister to support certificate action is itemized in the Notice of Suspension (NoS) or Notice of Cancellation (NoC) served to the document holder. The burden of proof rests with the Minister, who must prove on the balance of probabilities [subsection 15.(5)] of the Transportation Appeal Tribunal of Canada Act, that certificate action is warranted.

There are often similar characteristics or an interrelationship between the circumstances and criteria cited to support certificate action under the various provisions of section 7.1(1) of the Act. For example, a significant history of non-compliance may result in certificate action under Section 7.1(1)(a) (incompetence), or Section 7.1(1 (c) (public interest). In order to support a certificate action taken under Section 7.1(1)(a) —based on the incompetence of a CAD holder—it must be demonstrated that the repetitive non-compliant acts are the result of an inability to comply rather than an unwillingness to comply. In contrast, repetitive non-compliant behavior— which was not based on incompetence, but instead conducted to further other needs such as a business or financial goals— would support certificate action under Section 7.1(1)(c), for reason of public interest. In consideration of the available evidence, TCCA will determine the appropriate course of action to be taken.

There are a number of legislative requirements in both the Act and the CARs that specify the form and content of an NoS or NoC. Certificate action under any of the provisions of section 7.1(1) of the Act is not taken in response to an immediate threat to aviation safety (section 7.(1) of the Act deals with immediate threats to safety). Therefore, because an immediate threat to aviation safety is not present, the CAD holder is provided an effective date of the suspension or cancellation that is a later date than the date of service of the notice (typically 30 days). The notice will include a clear and accurate description of the nature of the alleged incompetence. In the case of suspension, because suspensions under the authority of this section of the Act are intended to deal with safety related matters, no duration for the suspension will be stipulated. However, an NoS will include the conditions necessary to resolve or rectify the incompetence (there may be more than one) in order to terminate the suspension.

Due to the nature of “incompetence” as defined above, certificate action for this reason is only applicable to an individual; it does not apply to a corporation.

The NoS or NoC will include a notification that the recipient must return the CAD to the Minister immediately after the suspension or cancellation takes effect. This is a requirement of section 103.03 of the CARs. Refusal (or failure) to return the CAD to the Minister following a suspension or cancellation constitutes a contravention of this section of the CARs.

This type of certificate action is subject to review by the TATC. Any person who has been served with an NoS or NoC for “incompetence” may request a review of the Minister’s decision before the TATC.

For more information on the subject, please refer to Staff Instruction SUR-014.

Invest a few minutes into your safe return home this winter...

...by reviewing section AIR 4.13 of the Transport Canada Aeronautical Information Manual (TC AIM), titled “First Aid Kits on Privately Owned and Operated Aircraft.”

TC AIM Snapshot: Monitoring 126.7 MHz and Position Reporting En route

Pilots operating VFR en route in uncontrolled airspace when not communicating on an MF, or an ATF, or VFR on an airway should continuously monitor 126.7 MHz and whenever practicable, broadcast their identification, position, altitude and intentions on this frequency to alert other VFR or IFR aircraft that may be in the vicinity. Although it is not mandatory to monitor 126.7 MHz and broadcast reports during VFR or VFR-OTT flights, pilots are encouraged to do so for their own protection.

(Ref: Transport Canada Aeronautical Information Manual (TC AIM), Section RAC 5.1)


1 The Concise Oxford Dictionary, Eight Edition, Oxford University Press, Oxford, U.K. 1990, p. 598

2Merriam Webster’s Collegiate Dictionary, Tenth Edition, Merriam-Webster, Springfield, MA, 1996, p. 588

3TATC File No. C-3128-21

4Mason v. Registered Nurses’ Assn. of British Columbia, 102 D.L.R. (3d) 225.

5 CAT File No. A 1789 25, p. 9

Note: The following accident synopses are Transportation Safety Board of Canada (TSB) Class 5 events, which occurred between August 1, 2011, and October 31, 2011. These occurrences do not meet the criteria of classes 1 through 4, and are recorded by the TSB for possible safety analysis, statistical reporting, or archival purposes. The narratives may have been updated by the TSB since publication. For more information on any individual event, please contact the TSB.

- On August 3, 2011, a Convair CV580 was landing at Kasba Lake, N.W.T., on a flight from Winnipeg, Man. The runway was bumpy, with soft and wet spots after recent rains. During the landing roll, the aircraft’s nose gear collapsed, and the aircraft came to rest on its nose. The passengers were deplaned with no injuries; the aircraft sustained substantial damage. TSB File A11C0128.

- On August 5, 2011, a Bell 407 helicopter was moving personnel in support of mining operations in the Hackett River Camp, Nun., area when an engine chip light came on. The pilot landed the helicopter and was following the normal engine cool-down procedure when a loud bang was heard and debris was projected in front of the helicopter. The pilot immediately activated the fuel shutoff and turned off the battery master. The pilot and four passengers exited the helicopter, and fire was observed in the engine area. The pilot returned to the helicopter and attempted to put out the fire with the hand-held cockpit fire extinguisher. The fire continued to burn; the pilot turned on the ELT and grabbed the hand-held radio. The helicopter was completely consumed by a post-crash fire. A cursory examination of the wreckage indicated an uncontained failure of the Allison 250 C47B engine. The engine was removed from the site and was shipped to the TSB Engineering Branch in Ottawa for examination. TSB File A11C0129.

- On August 6, 2011, a privately owned Enstrom 280 FX helicopter was landing on an unprepared sloped surface beside Lake du Chevreuil, Que. When the aircraft landed, its tail rotor struck the surface of the water and its drive shaft broke. The aircraft began rotating left before landing. The left skid was damaged. The accident occurred approximately 5 NM west of Duhamel, Que. Neither of the occupants was injured. TSB File A11Q0149.

- On August 11, 2011, the pilot of an AS 350 B2 helicopter had started the helicopter and began to perform the pre-flight hydraulic check. During the standard hydraulic accumulator test, the collective rose up and the helicopter became airborne. The pilot attempted to control the helicopter without hydraulic flight controls, but it struck the ground, bounced back into the air, rotated twice, and rolled over onto its left side. The pilot and three passengers escaped uninjured, but the helicopter was substantially damaged. The pilot had not engaged the collective lock. See TSB report #A06P0123 for identical circumstances. TSB File A11P0121.

- On August 13, 2011, a float-equipped Cessna 170B, with the pilot and two passengers on board, was taking off from Lake Sept-Îles, Que., when the pilot noticed that there was a personal watercraft ahead crossing his take-off path. The pilot completed a manoeuvre to avoid the personal watercraft, but the right wing touched the surface of the water, which caused the aircraft to stop suddenly. Both wings were significantly damaged. There were no injuries. TSB File A11Q0151.

- On August 14, 2011, a float-equipped Cessna 172N was on a recreational flight in the Caniapiscau, Que., region. While the aircraft was landing in very windy conditions on Lake Pau, the aircraft bounced. The pilot applied power to correct the situation. However, given that the aircraft’s speed had decreased too much, the effectiveness of the flight controls was reduced and was so low that the pilot was unable to regain control of the aircraft for landing. The aircraft’s right wing and nose touched the surface of the water first, and the aircraft came to a stop tilted, semi-submerged. The two occupants, who were wearing personal floatation devices (PFD), egressed and were quickly rescued by people from the nearby outfitter. There were no injuries. TSB File A11Q0153.

- On August 17, 2011, the pilot of a Cessna C150F was conducting circuits at Pokemouche Airport (CDA4) near Blanchard Settlement, N.B. At about 20:00 ADT, an engine RPM drop (Continental O-200) was noted as power was applied following a touch-and-go landing. The pilot elected to carry out a forced landing in a field adjacent to the airfield, but the aircraft’s vertical fin struck utility wires during the approach. The aircraft came to rest on the ground inverted. The pilot sustained minor injuries that were treated at the scene by paramedics. It was estimated that 10 L of fuel remained on board at the time of occurrence. The aircraft sustained substantial damage. TSB File A11A0048.

- On August 20, 2011, a privately registered Cessna T210M was parked on the ramp at Humboldt, Sask., after a local VFR flight. The pilot had the engine running in an effort to lower engine temperatures prior to shutting it down. The pilot had opened the left cabin door to allow cooler air into the cockpit. At this point, the male passenger in the rear seat exited the aircraft and stood in the open doorway talking with the pilot. Sometime shortly afterward, the lone female passenger seated in the right front seat unlatched the right cockpit door and exited the aircraft. After exiting the aircraft, the passenger walked towards the front of the aircraft and was fatally injured on contact with the rotating propeller. The pilot and other passenger sustained no physical injuries. TSB File A11C0135.

- On August 21, 2011, a privately registered Mooney M-20J was landing on Runway 30 at Thunder Bay, Ont., with a pilot and three passengers on board. During the landing roll, the pilot’s shirt became entangled on the landing gear selector, and the gear retracted. The aircraft settled on its belly and sustained damage to the belly and propeller. The pilot and passengers were uninjured. TSB File A11C0137.

- On August 23, 2011, a Bell 206B helicopter had landed on a makeshift lumber pad at a remote site 73 NM south of Smithers, B.C. Two passengers disembarked as the helicopter remained running and under the control of the pilot. As the helicopter was lifting off with only the pilot on board, a bear paw on the skid caught on a piece of lumber, which resulted in the helicopter rolling over. The pilot sustained minor injuries. Help was summoned by one of the passengers. The helicopter was substantially damaged. TSB File A11P0127.

- On August 24, 2011, a float-equipped Stinson 108-3 struck glassy water during an approach to land on Upper Arrow Lake at Nakusp, B.C. The aircraft overturned and submerged. The pilot was able to exit the aircraft, but the passenger did not exit and drowned in the overturned aircraft. TSB File A11P0128.

- On August 25, 2011, a privately registered Cessna U206D was landing on a road adjacent to a farm where the pilot was to repair farm equipment. During the final approach, the vertical fin struck an unobserved wire crossing the road. The aircraft landed safely. The vertical fin and rudder sustained substantial damage. There were no injuries. TSB File A11C0141.

- On August 28, 2011, a Cessna R182 was landing on Runway 30 at Charlo, N.B., after arriving from Bathurst, N.B. Upon touchdown, the aircraft landed on its belly, scraped along the runway for some distance, and came to rest on the paved surface. The pilot was the only occupant and was not injured; however, the aircraft was substantially damaged. The landing gear warning system was reported to be operating correctly, but the landing gear selector was not selected down prior to landing. TSB File A11A0054.

- On September 2, 2011, a Piper PA28-151 failed to outclimb rising terrain in a coulee during a private sightseeing flight west of Claresholm, Alta. During a 180° turn, the aircraft stalled and crashed into trees. Two occupants sustained minor injuries, and one was flown by MEDEVAC helicopter to Calgary with serious injuries. The aircraft was substantially damaged. TSB File A11W0129.

- On September 3, 2011, two gliders (an SZD-55-1 and a G102 ASTIR CS) were soaring in the same thermal about 7 NM southeast of the Invermere, B.C., airport when they collided. Both aircraft were substantially damaged and were incapable of controlled flight. Both aircraft struck the terrain and were destroyed. Neither pilot survived. The TSB is assisting the Office of the Chief Coroner for British Columbia in its investigation. TSB File A11P0134.

- On September 16, 2011, a Lake LA-4 amphibian airplane was taking off in VFR conditions between the St-Hyacinthe, Que., airport (CSU3) and Lake Geoffrion, Que. While the aircraft was attempting to land on water for the fourth time, it crashed in the lake. Both individuals were rescued by shoreline residents, who made their way to the aircraft in small boats. The passenger was fatally injured, and the pilot was severely injured. The aircraft was destroyed. TSB File A11Q0177.

- On September 16, 2011, an Aerospatiale AS350B1 helicopter was refuelled at Langley, B.C., and departed for Kelowna, B.C., at 18:20 PDT. The aircraft was last observed on radar at 3 800 ft in the vicinity of Hope, B.C. A citizen reported to the Kelowna tower that the aircraft was overdue. ATC had had no contact with the aircraft. The aircraft was found on September 20 by another helicopter operating in the area. The wreckage was located at 6 100 ft ASL on a north-facing 32º slope, indicating that the aircraft had turned back and reversed course. There was an intense post-impact fire that consumed most of the aircraft. The pilot was fatally injured. An installed 406 ELT was not working. TSB File A11P0139.

- On September 17, 2011, a Cessna 182P was inbound for Rockcliffe Airport (CYRO), Ont., and planned to land on Runway 27. During the final approach, the pilot lost sight of the runway in the setting sun and landed on Taxiway A, which was parallel to the runway. During the landing rollout, the pilot swerved to the left to avoid a taxiing aircraft and struck a parked aircraft. The pilot was uninjured; however, the landing aircraft was significantly damaged. TSB File A11O0187.

- On September 18, 2011, the unlicensed pilot of an ultralight Aeros Model 582 had conducted numerous taxi runs to become familiar with the aircraft before departing from a private property in Carroll’s Corner, N.S., for a local flight. This was the first flight for the pilot in this model of ultralight. After climbing above the trees shortly after takeoff, the ultralight pitched nose down, descended rapidly and crashed into a pond. The pilot, the sole occupant of the aircraft, was fatally injured. Fuel leaked into the pond. There was no indication of an in-flight structural failure, and the engine was operating at the time of impact. The pilot had about 9 hr of dual-flight training in a different model of ultralight. The pilot did not have any ground school training, nor was he authorized to fly solo. TSB File A11A0061.

- On September 23, 2011, a Cessna U206G was conducting a VFR charter flight from Fort Simpson, N.W.T., to the Root River Camp with two drums of avgas. The aircraft departed Fort Simpson in VFR conditions and followed the Root River. After approximately 1 hr of flying, the pilot began to encounter lower ceilings and visibilities. The pilot turned into what was thought to be the valley where the camp was located, but it was actually a box canyon. During an attempt to turn and climb out of the rising terrain, the right wing struck terrain and then the ground. The pilot sustained minor injuries and was located a few hours later with the help of the functioning 406 ELT. TSB File A11W0146.

- On September 23, 2011, an amateur-built, float-equipped Wagaero Sport Trainer was on a local VFR flight with the pilot and a passenger on board. When the aircraft took off from Lake Jourdain, Que., it entered a bank of fog. The pilot made a turn and the floats struck the surface of the water. The aircraft was severely damaged. Neither occupant was injured in the accident. TSB File A11Q0183.

- On September 24, 2011, a float-equipped Wagaero Sportsman 2+2 took off from Lake Husky, Que., for a local flight with the pilot and a passenger on board. While the aircraft was returning and was on final for the lake, it experienced fuel starvation. The seaplane struck trees and crashed 20 m before it was to land on Lake Husky. Neither occupant was injured in the accident. According to the information that was obtained, a blocked fuel pipe caused the loss of power. The 406 ELT went off upon impact. TSB File A11Q0184.

- On September 24, 2011, an R44 II helicopter took off from Saint-Joseph-du-Lac, Que. at around 20:30 EDST on a VFR night flight to Saint-Jean-des-Piles, Que., with only the pilot on board. The aircraft struck the surface of Saint-Maurice River when it was approximately 350 m from its destination. The aircraft quickly sank. The pilot egressed from the cockpit and swam to shore, where he was rescued. He sustained serious injuries. TSB File A11Q0182.

- On October 2, 2011, an amateur-built, float-equipped Beaver des Pauvres took off from Nicolet River, Que., for the Outardes-4 dam, located north of Baie-Comeau, Que. While the aircraft was en route, the weather deteriorated, and the pilot conducted a precautionary landing on water in the southwestern portion of Jacques Cartier Lake, located in the Réserve faunique des Laurentides, at around 10:00 EST. Judging that the weather had improved, he took off again at around 12:30 EST. He found himself in a valley in which it was impossible to turn around. Due to the blanket of clouds, the pilot descended so low that the aircraft struck the tops of spruce trees. The seaplane crashed at around 13:00 EST and was significantly damaged. The pilot was not injured. The impact was not enough to set off the ELT. The pilot had a global positioning system (GPS) that could identify his location. Furthermore, he was able to communicate via cell phone and be rescued, as he was close to Route 175. TSB File A11Q0186.

- On October 19, 2011, a Cessna 185 was conducting an engine run-up in the run-up designated area at Rouyn-Noranda airport (CYUY), Que., when a Boeing 737 parked 300 ft away increased engine power to taxi. The C185 pilot, realizing the B737 was advancing, applied engine power in an attempt to taxi further away; however, the C185’s right wing lifted and the aircraft fell on its right side. The pilot and passenger were not injured. The C185 was substantially damaged. The C185 pilot was not aware that the B737 was preparing to leave and did not believe his aircraft was close enough to the B737 to be affected by the jet blast. The B737 flagman believed the C185 was far enough away and would not be affected by the jet blast. The flight service station (FSS) had not advised either crew of the presence of the other aircraft. TSB File A11Q0190.

- On October 26, 2011, a chartered Cessna 180J was climbing to 5 500 ft ASL towards St-Boniface-de-Shawinigan, Que. At approximately 3 500 ft ASL, the pilot noticed that the Continental O-470-S engine had lost power and stabilized the aircraft. The pilot turned around to come back and land and applied carburetor de-icing. The engine misfired a few times. While the aircraft was flying by the mountaintop upon its return, it entered an area of downdrafting air. While it was descending into the valley, the aircraft struck the treetops and came to a stop in the trees. The pilot and two passengers were not injured, and the aircraft was significantly damaged. TSB File A11Q0198.

- On October 30, 2011, a Fairchild SA227-AC was on an IFR flight from Montréal-Trudeau International Airport (CYUL), Que., to Kitchener/Waterloo (CYKF), Ont., with two pilots and two passengers on board. After the aircraft pushed back, the pilots were instructed to set the brakes and disconnect from the towing tractor. While personnel were still working near the nose wheel, the airplane started moving forward towards the tractor. The personnel moved away; the nose of the airplane struck the tractor and was damaged. There were no injuries. TSB File A11Q0203.

- On October 31, 2011, a float-equipped Champion 7GCBX took off on a VFR flight from Lake Labrecque, Que., to Lake Houlière, Que., with only the pilot on board. Approximately 30 min after takeoff, the pilot conducted a precautionary water landing on Péribonka River when he encountered low visibility conditions. When the aircraft landed on water, the pilot lost his visual references in the fog and the seaplane landed in a marsh on the shore of the river. During the ground run, a wing and a float broke off. The airplane caught fire after it came to a stop. The 406 ELT went off. The pilot was not injured in the accident. TSB File A11Q0204.

Artist's impression of choices faced by the pilot, who was unable to climb properly after takeoff.

On August 22, 1997, a float-equipped Piper Aztec with three occupants on board attempted to take off from Squaw Lake, Quebec, under visual flight rules. The pilot first tried to take off northward, but had to abort the take-off because a fuel tank cap was open. A few moments later, he began the take-off run southward; the aircraft travelled about 8000 ft. before becoming airborne. The aircraft did not attain a high rate of climb, but continued its flight at about 100 ft. above the trees.

The flight service station (FSS) specialist, who was following the aircraft visually, noticed a brief power outage at his work station then saw a cloud of smoke rising on the horizon. He tried unsuccessfully several times to contact the aircraft by radio. He then asked a helicopter flying over the area to go to the source of the smoke and check whether an accident had occurred. The helicopter pilot arrived a few minutes later and confirmed that the aircraft had crashed after striking a high-voltage line.

Following the crash, an intense fire then erupted, but the pilot was able to evacuate the aircraft by the left forward door, passing through the flames and suffering serious injuries. The two passengers were unable to evacuate and were fatally injured. This synopsis is based on Transportation Safety Board of Canada (TSB) Final Report A97Q0183.

The pilot had little rest in the 48 hr. before the flight. He had been busy preparing his hunting camps for the season that was just opening. Logistics and monitoring his employees took a great deal of his time. He had slept for only about three hours on each of the two nights preceding the flight. On the morning of the occurrence, the pilot left his home at around six o’clock to take a commercial flight from Dorval to Schefferville, Quebec. From Schefferville, he was to fly his private aircraft to take two cooks to two different camps. The clients of the pilot’s hunting camps had already taken off and were en route to their destinations.

The aircraft was loaded by the pilot’s two employees at the Air Saguenay dock while he was busy preparing the aircraft for the flight. No baggage or cargo was weighed on the scale available on the dock. According to the TSB, two weight and centre of gravity (C of G) estimates were calculated. The first estimate was evaluated by the pilot, and it showed that the aircraft was not overloaded and that the C of G was within the envelope. The maximum zero fuel weight, which is 4400 lb., was exceeded by 113 lb. A second evaluation was done according to the statements of the employees who loaded the aircraft. According to that evaluation, the aircraft was overloaded by 322.5 lb., and the C of G was 5.97 in. aft of the aft limit and outside the envelope. In that configuration, the maximum zero fuel weight was exceeded by 630.5 lb.

The position of the C of G plays a very important role in longitudinal stability. If the aircraft is loaded so that the C of G is too far aft, the aircraft will tend to adopt a nose-up attitude rather than one that is nose-down. Inherent stability will be lacking, and even though it is possible to correct this situation by moving the elevator down, longitudinal control of the aircraft will still be difficult, or impossible in some cases. Weight affects the aircraft’s stall speed. Additional weight forces the aircraft to maintain a greater angle of attack to produce the lift necessary to sustain flight. Thus, the critical angle of attack will be attained at a higher speed. The greater the angle of attack, the greater the drag will be. At a specific angle of attack, the aircraft enters the slow flying range. In the slow-flying range, if the angle of attack is increased, lift does not increase further; on the contrary, it decreases and drag increases. A slight increase in angle of attack may result in a stall.

A few minutes after the occurrence, the Squaw Lake winds were from 120° True at 3 kt. According to the pilot, there was a light tail wind on the takeoff toward the south.

Squaw Lake is oriented northwest/southeast and is about 2½ mi. Long. To the southeast, at the end of the lake, there is a valley between two hills. The elevation of the lake is 1616 ft. above sea level (ASL), whereas the elevation at the first point of impact of the aircraft was 1800 ft. ASL.

The aircraft apparently covered about 8000 ft. before lifting off and flew for about 8000 ft. before striking the ground. The pilot stated that he realized that the aircraft was not achieving its usual performance during the initial climb. During the take-off run, the aircraft travelled for a longer than normal distance before taking off. The pilot attributed that situation to the tail wind.

Normally, once the aircraft was flying, the pilot lowered its nose to retract the flaps and allow the aircraft to accelerate at the best rate of climb. In this case, the pilot could not retract the flaps because of the shoreline and the obstacles that were quickly approaching. He pulled back on the controls and tried to gain altitude while maintaining a speed of approximately 80 mph, with the flaps still down 15°. The pilot attempted to clear the obstacles on his flight path, but when the high-voltage wires appeared ahead, he could not take evasive action to clear the obstacle. The aircraft struck the high-voltage lines and a wooden pole, then went nose down and pivoted around the pole before crashing on the ground.

According to an experienced pilot with many flying hours on the same float-equipped aircraft type, the aircraft requires a distance of about 3000 ft. for take-off when loaded to the maximum weight of 5200 lb., with the flaps at 15. For example, on a lake a mile and a half long, if the aircraft does not lift off within the set limits, the loading must be revised to distribute the weight better and the floats must be checked to make certain they do not contain any water. According to this pilot, the most critical factor is not to exceed the 150-lb. limit in the aft baggage hold so as not to move the C of G aft outside the envelope; that would cause the aircraft to be nose-up, both during the take-off run and when airborne.

Analysis - The pilot had not taken enough rest when preparing for the flight and had not allowed enough time to prepare his camps for the hunting season, placing himself under pressure. He was highly stressed because of the very tight schedules he had set for himself. The pilot, pressed for time, did not check the cargo weight on the scale available on the loading dock and decided to take off with an aircraft that was overloaded and whose C of G was too far aft. Because he knew that his clients were already flying to the camps and that the cooks had not yet arrived, the pilot was determined to take off on his second attempt. The aircraft used a greater than normal distance before lifting off. At any time during this second attempt, the pilot could have aborted the take-off run and revised his load, but he decided to continue.

The aircraft took an abnormally long distance before rising out of the water because of its nose-up attitude, which was caused by the fact that the C of G was outside the envelope and displaced aft, and because of the excess weight. This nose-up attitude of the floats in the water caused drag that prevented the aircraft from accelerating within the normal distance during the take-off run. After 8000 ft. of take-off run, which is over twice the distance normally required, the aircraft lifted off, partly because of the ground effects phenomenon.

Then, seeing the approaching obstacles on the shoreline, the pilot pulled back on the controls to try to clear them. The aircraft was travelling at 80 mph, which is well below the recommended climb speed of 120 mph and even below the speed for the best climb angle of 107 mph. Because of its configuration, the aircraft stall speed was higher than normal. It can thus be concluded that the aircraft was in the slow-flying range. The more the pilot pulled back the controls, the greater the drag. Thus, the aircraft could not attain a climb rate sufficient to clear the obstacles on its flight path and it struck the high-voltage lines and a pole.

The TSB concluded that as a result of its excessive weight and its C of G outside the envelope, the aircraft lifted off only after a long run and it could not maintain a rate of climb sufficient to clear the obstacles on its flight path. Contributing to the occurrence were the pilot’s stress, disorganization and fatigue.

Now, although technically accurate, was this really a C of G accident? Or was it a human accident? What truly allowed the events to unfold as they did? We, as pilots, have the ability to control, to a certain degree at least, the sequence of events. Let’s call it The Human Element - the most important of them all.

Attitude Indicator

Dear Editor,

I would like to respond to the essay on Kennedy’s fatal spiral dive accident, published in Aviation Safety Letter 4/99. Developing a new attitude indicator that combines a moving horizon and miniature aircraft would make little difference to whether a pilot would be able to recover from a spiral dive. The fact is that, typically, the pilot misinterprets its indication (no matter what the design) and fails to cross-check with other instruments — this is a question of training and proficiency. If the pilot gets more comfort from seeing the little airplane in a banked attitude, he or she can look at the turn co-ordinator.

If the accident was indeed a result of a spiral dive as a result of disorientation, the emphasis of the investigation should be on the human aspects so others can learn how to break the chain of events that led to the tragedy. This means recognizing the pressure to get to a destination, especially when behind schedule. Often we do not want to disappoint our passengers and this self-imposed pressure can push us to fly into adverse conditions; this is known as "get-home itis." We also need to recognize the environment we are getting into, including the weather and the type of aircraft; recognizing our own limits against this backdrop of pressure and environment may be the key to prevent such occurrences. Let’s get the training to enhance our abilities or be prepared to say "no" if conditions exceed them.

James Greenhill
Montreal, Quebec

Thank you Mr. Greenhill. Indeed your comments about self-imposed pressure, environment (night VFR among others), and the pilot’s own abilities are crucially important, and likely responsible, in some part, for that accident. We can learn a lot from your letter alone. However, I do not believe the article by Dr. Roscoe meant to ignore those issues, rather to discuss a very specific instrument and how it could be improved. It’s like "thinking outside the box" and it probably deserves more scrutiny. In fairness to all, here are the main points of Aero Innovation’s response to your letter. - Ed.

Dear Mr. Greenhill,

Your comments on the decision to go flying or not are relevant but do not address the reasons pilots, despite their level of experience, risk calculation, and flight planning, fail to recognize spirals when they occur, and why pilots hold full ailerons in the direction of turn all the way to ground impact (a fact known when flight data recorders (FDR) are present). In the U.S. alone, this happens more than twice a week, sometimes to highly experienced and current pilots.

It is not only reasonable but also a duty to improve poorly engineered instruments if the improvements prevent pilots from inadvertently entering spiral dives and/or ease the recognition of a dive and/or suggest proper recovery procedures. This is more than just a training issue, as all of us eventually meet a level of mental saturation triggering instinctively humane reactions not always in accordance with good airmanship or past (sometimes distant) training. This is what human factors are all about. Thank you for sharing your views with us.

Jean LaRoche
President of Aero Innovation

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