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The Aviation Safety Letter (ASL) is published quarterly by Transport Canada, Civil Aviation. The ASL includes articles that address aviation safety from all perspectives, such as safety insight derived from accidents and incidents, information tailored to the needs of maintenance and servicing personnel.

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Guest Editorial Re Targeted Inspections

  • Details re Transport Canada's new "Targeted Inspections."
  • Yearly inspection plans to cover the full spectrum of the aviation industry versus simply the higher risk sectors.
  • Between April 2018 and March 2019, TC will conduct targeted inspections of heliports, aerial work operators, private operators and the general aviation community.
  • Re General Aviation: To provide baseline compliance data to support more safety promotion and education with the general aviation community.
  • To make better use of data to focus in on risk areas and plan surveillance activities.

Crew Resource Management

  • The Transportation Safety Board (TSB) has acknowledged that human factors are the primary cause in a large percentage of aircraft fatalities.
  • Transport Canada (TC) has introduced Contemporary Crew Resource Management (CRM) Training pertaining to Commercial Flight Standards.
  • Details re the above.

Flight Crew Fatigue Management

  • Prescriptive Approach vs. Performance-based Approach for Commercial Air Operators.

Mental Health in Aviation

  • Routine stress overload can lead to mental distress in the form of fatigue, distraction and even burnout.
  • Aviation-related functions … require a high level of situational awareness, laser focus and the ability to make good decisions when required.
  • Discussion on the social stigma surrounding mental health.

Technical Standard Order (TSO) Workshop

  • Details of the TSO workshop, hosted by Canada in 2017.

TSB Final Report Summaries

TSB Final Report A15Q0126 - Loss of Directional Control and Collision with Terrain

  • Crash of a Bell 206B Helicopter. Two fatalities. Three serious injuries.
  • Loss of control was due to LTE (Loss of Tail-rotor Effectiveness) caused by vortex ring state.
  • No in-flight training on LTE is provided on account of the risks this would entail. Consequently, the pilot was not familiar with the very precise skills required to control the aircraft when such a loss of effectiveness occurred close to the ground.
  • Insufficient tail rotor thrust, which can be identified by a yaw to the right, can be countered by:
    • 1. apply full left anti-torque pedal and move the cyclic control stick forward; and
    • 2. if altitude is sufficient, reduce power.
  • The female passenger sustained fatal abdominal injuries, possibly due to the fact that her lap belt was not fitted correctly.

You Have Control… or Do You?

  • Detailed explanation of the cause of LTE (Loss of Tail-rotor Effectiveness) .
  • Ways to avoid/recover from LTE.

TSB Final Report A15O0188 - Collision with Terrain Cessna 182H

  • A Cessna 182H crashed shortly after a night takeoff, killing both occupants.
  • The aircraft was destroyed in a post-impact fire, but information from the GPS was retrieved.
  • The Cessna had been operated on floats all summer but was now returning home as a landplane.
  • The Pilot initiated a climbing right turn immediately after takeoff, banking into a dark area with no discernible horizon.
  • The Pilot did not have an Instrument Rating.
  • Night departures from aerodromes with limited cultural and ambient lighting sources present several hazards to pilots, especially to those without an instrument rating or current night flight experience.
  • Night flying over featureless terrain such as wooded areas - called black hole conditions - can lead to Spatial Disorientation.
  • A flight conducted over an area where there is inadequate ambient illumination to clearly discern a horizon would not meet the requirements for operation under VFR.
  • The pilot, who was probably not proficient at flying with reference to the instruments, may have become spatially disoriented after losing visual reference to the surface off the departure end of the runway and lost control of the aircraft.
  • No Flight Plan was filed and - although the aircraft was equipped with an emergency locator transmitter (ELT) - it was not activated by impact forces.

TSB Final Report A15H0002 - Collision with Terrain Airbus Industrie A320-211

  • Report on the collision with terrain of an Airbus A320-211.
  • During a night landing, the aircraft severed power lines, and then struck the snow-covered ground about 740 ft before the runway threshold.
  • The aircraft continued airborne through the localizer antenna array, and then struck the ground twice more before sliding along the runway and coming to rest on the left side of the runway, about 1900 ft beyond the threshold.
  • The aircraft was evacuated; 25 people sustained injuries and were taken to local hospitals.
  • The aircraft was destroyed, although there was no post-impact fire.
  • The emergency locator transmitter was not activated.

Transport Canada's E-Bulletin Notification Service

  • E-Bulletin gives pilots the opportunity to receive e-mail notifications of all newly issued Aviation Safety Letter, Advisory Circulars, Transport Canada Aeronautical Information Manual (TC AIM) and the Feedback as soon as they are published.
  • To subscribe, please visit the Transport Canada Civil Aviation e-Bulletin page.

Send ASL Your Stories!

  • A request for pilots to send their personal stories to:
    Editor,
    Aviation Safety Letter Transport Canada,
    AARTT Place de Ville, Tower C
    Ottawa, Ontario, K1A 0N8
  • Anonymity is available upon request.

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We would like to acknowledge the financial support of the Government of Canada for this initiative through the Search and Rescue New Initiative Fund (SAR NIF).