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The crew was on a flight from Kuujjuarapik to Umiujaq, Quebec. During the turn onto the final approach to Umiujaq Airport runway 21, the aircraft stalled. The pilot-in-command regained control of the aircraft but he was unable to pull up sufficiently to clear the obstacles, and the aircraft crashed. The two pilots and two of the 11 passengers sustained minor injuries.
The Board determined that the stalling speed of the aircraft increased due to ice on the leading edge of the wings and because the pilot made a steep turn; the aircraft stalled at an altitude from which the pilot was unable to recover. A contributing factor was the crew's decision to continue the visual approach into Umiujaq despite the weather conditions reported.
The flight procedure that brings into question the intent of the regulation is an en route IFR descent in instrument meteorological conditions (IMC) to conduct a VFR landing. Air Regulation 553 requires that aircraft in IFR flight be flown at an altitude 1,000 feet above the highest obstacle within 5 miles of the estimated position of the aircraft, except when taking off or landing (3). The descent procedure used by the aircrew in this occurrence, and interpreted by the TC regional office as being acceptable, could eliminate this safety margin. Using a line of thinking consistent with this interpretation, a crew could descend an aircraft in IMC, without being on an approved instrument approach, to an altitude where visual meteorological conditions (VMC) were anticipated, as long as the descent was considered to be for the purpose of landing. The Board and TC's head office both believe that this was not the intent of the regulation.
The Board is concerned that regulatory officials and the operator of a fleet of state aircraft apparently did not question the appropriateness of a procedure that put aircraft, crew, and passengers at an increased level of risk. Therefore, the Board recommends that:
Transport Canada agrees that, in general, further efforts are required to eliminate confusion that may exist related to IFR flight in uncontrolled airspace. However, further clarification of Air Regulation (AR) 553 (which requires that aircraft maintain certain altitudes and distances from obstacles while operating under IFR) is unwarranted if related regulations and guidance material are considered.
Regulations cannot be considered in isolation of other relevant regulations or guidance material; to do so may lead to misinterpretation. When other regulations and guidance material are considered, the intent of AR 553 becomes clear. For instance, paragraph 548(1) (c) is relevant in this case, and applies to the pilot-in-command of an aircraft that is in IFR flight of IFR weather conditions-..."where the aircraft makes an approach to an airdrome or a runway, ensure that the approach is made in accordance with the instrument approach procedure, unless otherwise authorized by the appropriate air traffic control unit." At the time of the accident there was no published instrument approach procedure for Umiujaq, Quebec.
Guidance material is contained in AIP Canada in Section 9.0 - Instrument Flight Rules - Arrival Procedures, paragraph 9.7.1 "In accordance with Air Reg. s.553, the aircraft shall be flown at an altitude of at least 1,000 feet above the highest obstacle located within a horizontal radius of 5 miles from the estimated position of the aircraft in flight until the required visual reference is acquired in order to conduct a normal landing. Pilots are cautioned that conducting a contact approach in minimum visibility conditions introduces hazards to flight not experienced when flying IFR procedures." When considered together, the relevant regulations and guidance material provide clear intent.
In Canada, several departments and agencies of the federal and provincial governments operate fleets of aircraft. These fleets vary in size from just a few aircraft to over 100 aircraft, often with a mixture of aircraft types in any one fleet. The aircraft are frequently used to transport passengers, albeit not in a commercial capacity. The state aircraft generally operate under Air Navigation Order (ANO) I, No. 2, which regulates the transport of passengers in private aircraft. Private aircraft in this context include state and corporate aircraft. Thus, a private aircraft with a passenger-carrying capacity of only a few passengers and state/corporate aircraft with significant passenger-carrying capacity (often significantly greater than that of the accident aircraft type) are treated in a similar manner from a regulatory perspective. The Fonds du Service Aérien Gouvernemental is classified as a state-owned operation and was operating under ANO I, No. 2.
Commercial operations are generally conducted in accordance with ANO VII, No. 2 (large aircraft), and ANO VII, No. 3 (small aircraft). The aircraft type involved in this accident would be operated under ANO VII, No. 2, in a commercial operation. There are significant differences between ANO I, No. 2, operations and ANO VII (particularly ANO VII, No. 2) operations in the areas of the requirement for an operating certificate, operational requirements, crew training and qualifications, and regulatory overview.
In the late 1980s, the predecessor to the TSB, the Canadian Aviation Safety Board (CASB), became concerned about the number of occurrences involving another operator of a large fleet of state aircraft, the RCMP. It was noted at that time that a number of the practices and procedures meant to enhance safety in the commercial aviation sector were absent in the day-to-day operation of that fleet. The CASB suggested that the operator request an independent safety survey to assist in identifying shortcomings in the operation. A safety survey was subsequently done by TC and corrective measures were taken. Some of these measures were in excess of ANO I, No. 2, requirements and more in line with ANO VII requirements. The number of significant occurrences involving RCMP aircraft has reduced considerably since 1990.
In providing its regulatory overview of commercial operators, Transport Canada uses risk management indicators to identify those carriers possibly requiring extra surveillance and audit. However, operators of state aircraft do not come under the same regulatory scrutiny; thus, indicators of increasing risk are less likely to be detected. The operation of TC's own fleet of aircraft is voluntarily subjected to the requirements of an operating certificate similar to that of commercial carriers.
The recently announced CARs will require state and private operators of large or turbine-powered, pressurized passenger aircraft to adhere to more demanding safety standards. However, these standards are still not equivalent to those applicable to commercial air carriers. It is recognized that the operations in which state aircraft are often engaged are unique, and that, for the most part, they do not involve the travelling public. Yet, when passengers are regularly carried on state aircraft, it is reasonable for these passengers to expect that the aircraft and aircrew involved in state operations are subject to the same regulatory requirements as commercial carriers. The Board believes, therefore, that state operations would benefit from the increased standards and regulatory overview applicable to commercial operations. Therefore, the Board recommends that:
The Department of Transport require that the operators of state aircraft be subject to regulatory overview, as practicable, equivalent to that of similar commercial operations. (A96-03)
The Quebec Government Air Service is one of the larger fleet operators regulated by ANO Series 1, No 2 (CAR 604) and operates a range of aircraft including small aircraft, fire suppression aircraft and several large passenger carrying aeroplanes. While the operation of Convair CV580 aircraft in an employee transportation role appears to be quite active, this operation is not a publicity available air service and as such does not warrant the imposition of increased commercial standards.
Air Sandy flight 3101, a Piper PA-31 Navajo with one pilot and four passengers on board, had departed Sioux Lookout on a flight to Red Lake, Ontario. Bearskin Airlines flight 362, a Fairchild Swearingen Metro 23 with a crew of two and one passenger on board, was inbound to Sioux Lookout on a flight from Red Lake. The two aircraft collided at 4,500 feet above sea level, approximately 12 nautical miles northwest of Sioux Lookout. All eight occupants were fatally injured.
The Board determined that neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Subsequent to the accident, Bearskin Airlines developed procedures to reduce the risk of mid-air collisions in the busy Sioux Lookout area. These procedures include a requirement that all Bearskin aircraft be flown at a speed of less than 150 knots when operating within 5 nm of the Sioux Lookout airport. This reduction in airspeed should decrease the probability of mid-air collision by increasing both the likelihood of detecting conflicting traffic and the time available to take evasive action once conflicting traffic has been detected. 041b061a72