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AVIATION OCCURREN CE REPORT EN GIN E POWER LOSS/LOSS OF CON TROL ARCTIC WIN GS AN D ROTORS PILATUS BRITTEN -N ORMAN BN 2A-20

ISLAN D ER C-GMOP TUKTOYAKTUK, N ORTHWEST TERRITORIES 7.7 mi SE 03 D ECEMBER 1993 REPORT N UMBER A93W0204

MANDATE OF THE TSB


The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! ! ! ! ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; reporting publicly on its investigations and public inquiries and on the related findings; identifying safety deficiencies as evidenced by transportation occurrences; making recommendations designed to eliminate or reduce any such safety deficiencies; and conducting special studies and special investigations on transportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings.

INDEPENDENCE To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations.

The Transp ortation Safety Board of Canad a (TSB) investigated this occu rrence for the p u rp ose of ad vancing transp ortation safety. It is not the fu nction of the Board to assign fau lt or d eterm ine civil or crim inal liability.

Aviation Occurrence Rep ort

Engine Pow er Loss/ Loss of Control Arctic Wings and Rotors Pilatu s Britten-N orm an BN 2A-20 Island er C-GMOP Tu ktoyaktu k, N orthw est Territories 7.7 m i SE 03 Decem ber 1993 Rep ort N u m ber A93W0204

Synopsis
The pilot and passengers on board the Britten-N orm an Island er w ere on a sched u led night visu al flight ru les flight from Tu ktoyaktu k to Inu vik, N orthw est Territories. Ap p roxim ately four m inu tes after take-off, the pilot rep orted to the Tu ktoyaktuk Flight Service Station that he had an engine problem and w as retu rning to the airp ort. When the aircraft d id not arrive, an air and grou nd search w as initiated . The w reckage w as located three hou rs later, on an icecovered lake ap p roxim ately eight m iles sou theast of the airp ort. There w ere no su rvivors. The Board d eterm ined that a m agneto im p u lse cou p ling, w orn beyond the prescribed lim its, resulted in the failu re of the right engine. Follow ing the engine failu re, the pilot m istrim m ed the ru d d er and w as unable to m aintain control of the aircraft. Ce rap p ort est galem ent d isp onible en franais.

TA BLE O F C O N TEN TS

Table of Contents
Page

1.0

Factu al Inform ation


1.1 1.2 1.3 1.4 1.5 1.5.1 1.6 1.6.1 1.6.2 1.6.3 1.6.4 1.7 1.7.1 1.7.2 1.7.3 1.7.4 1.7.5 1.7.6 1.7.7 1.8 1.9 1.10 1.11 1.12 1.12.1 1.12.2 1.12.3 1.12.4 1.12.5 1.12.6 1.12.7 1.12.8 1.12.9 1.13 1.14

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1 1 2 2 2 2 3 4 5 5 5 6 6 6 6 7 7 7 8 8 9

H istory of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inju ries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dam age to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Dam age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personnel Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pilot's Work Sched u le . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Record s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Weight and Balance Calcu lations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Perform ance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single Engine Proced u res . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meteorological Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Weather Synop sis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H ou rly Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pilot Rep orts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VFR Flight at N ight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N ight VFR in Com m ercial Op erations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Training Environm ent vs. Op erational Environm ent . . . . . . . . . . . . . . . . . . . . Training Requ irem ents: AN O VII N o. 3 vs. AN O VII N o. 2 . . . . . . . . . . . . . . Aid s to N avigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Com m u nications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Aerod rom e Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Flight Record ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wreckage and Im p act Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Aircraft Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Instru m ent Exam ination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Instru m ent Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Stall Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Engine and Prop eller Exam ination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Engine Magneto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Service Bu lletins and Airw orthiness Directives . . . . . . . . . . . . . . . . . . . . . . . . . 13 Aircraft Controls Exam ination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Ru d d er Trim Op eration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Med ical Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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iii

TA BLE O F C O N TEN TS 1.15 1.16 1.16.1 1.17 1.17.1 1.17.2 1.17.3 1.17.4 1.17.5 Su rvival Asp ects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Britten-N orm an Test Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Ad d itional Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Com p any Op erations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Maintenance Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Pilot Du ty Tim es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Pilot Fatigu e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Transfer Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.0

Analysis
2.1 2.2 2.3 2.4 2.5 2.5.1 2.6 2.6.1 2.6.2 2.6.3 2.6.4 2.7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Introd u ction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Maintenance Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 The Engine Failu re . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Altitu d e and Position on Dep artu re . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Pilot Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Fatigu e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Stall Warning and Instru m ent Lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Single-Engine Proced u res/ Perform ance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Ru d d er Trim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 The Loss of Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Pilot Training and Workload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

3.0

Conclu sions
3.1 3.2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Find ings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Cau ses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

4.0

Safety Action
4.1 4.1.1 4.1.2 4.1.3 4.2 4.2.1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Action Taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Magneto Insp ection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mand atory Service Bu lletin MS645 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Regu latory Au d its and Su rveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Action Requ ired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 N ight VFR Com m ercial Op erations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

iv

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TA BLE O F C O N TEN TS 4.2.2 4.2.2.1 4.2.3 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 N ight Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Aircraft Grou p ing for Pilot Proficiency Checks (PPC) . . . . . . . . . . . . . . . . . . . 32

5.0

Ap p end ices
Ap p end ix A - Flight Locale - C-GMOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Ap p end ix B - Map of Flight Path - C-GMOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Ap p end ix C - List of Su p p orting Rep orts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ap p end ix D - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

List of Figu res


Figu re 1 - Im p u lse Cou p ling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Figu re 2 - Ru d d er Trim System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N

1.0 Factual Information


1.1 History of the Flight

On 03 Decem ber 1993, a Britten-N orm an BN 2A-20 Island er, registration C-GMOP, ow ned and op erated by Arctic Wings and Rotors, d ep arted Tu ktoyaktu k, N orthw est Territories, on a night visu al flight ru les (VFR)1 flight to the Inu vik tow nsite airstrip. On board w ere the pilot and six p assengers. The pilot took off from ru nw ay 09 at 1706:34 m ou ntain stand ard tim e (MST)2, and had tu rned the aircraft to a sou therly d irection w hen the right engine (Textron Lycom ing IO540-K1B5) lost all pow er (see Ap p end ix A). At 1710:40, the pilot rep orted to Tu ktoyaktu k Flight Service Station (FSS) that he had an engine p roblem and w as trying to get back to the airport. At 1711:44, he reported that he w as "p resently head ing back to the airp ort at this tim e." At 1711:58, he reported "show ing six m iles back from the airp ort at this tim e." The FSS sp ecialist asked if he w as d eclaring an em ergency, and the pilot's resp onse w as ind ecisive. Du ring the last rad io transm ission, there w ere ind ications of stress in the pilot's voice; how ever, there w as no fu rther m ention of the sp ecific natu re of the problem . The pilot d id not rep ort his altitud e d u ring the conversations w ith the FSS. The transm ission lasted ap p roxim ately 15 second s and end ed at 1713:03. When the aircraft d id not retu rn to the airp ort, an air and grou nd search w as initiated . The aircraft w as located on an ice-covered lake ap p roxim ately eight m iles sou theast of the airp ort. The aircraft stru ck the ice in a steep nose-d ow n attitu d e. The engines and front of the aircraft p enetrated the app roxim ately tw o-foot-thick layer of ice. The rem aind er of the fu selage, w ings, and em p ennage rem ained on the ice surface. The seven occu pants w ere fatally inju red . The accid ent occu rred d u ring the hours of d arkness at app roxim ately 1713 MST, at latitud e 6920'N , longitu d e 13256'W, at an elevation of ap p roxim ately 50 feet above sea level (asl)3.

1.2

Injuries to Persons
Crew Passengers 6 Others Total 7 -

Fatal Serious

1 -

See G lo ssar y (A p p en d ix D ) fo r all ab b r ev ia tion s an d acr on y m s. A ll tim es a r e M ST (C o o r d in a ted U n iv er sa l Tim e [U TC ] m in u s sev en h ou r s) u n less o th er w ise stated . U n its ar e con sisten t w ith official m an u als, d ocu m en ts, rep or ts, an d in str u ction s u sed b y or issu ed to th e cr ew .

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N

Minor/ N one Total

1.3

Damage to A ircraft

The aircraft w as d estroyed .

1.4
N one.

Other Damage

1.5

Personnel Information
Pilot-in-command

Age Pilot Licence Med ical Exp iry Date Total Flying H ou rs H ou rs on Typ e H ou rs Last 90 Days H ou rs on Typ e Last 90 Days H ours on Duty Prior to Occurrence H ours Off Duty Prior to Work Period

27 ATPL 01 May 94 3,224 848 298 208 8 12

The pilot held a valid licence w ith a Class I instru m ent rating. H e occu p ied the left front seat, and w as at the controls at the tim e of the accid ent. The right front seat w as unoccu p ied . The pilot received his private pilot licence in 1986, his com m ercial licence in March 1987, a seap lane rating in May 1987, and m u lti-engine and instru m ent rating in Ap ril 1988. H is recent flying, d u ring training on the PA-31 N avajo w ith the chief pilot, w as d escribed as "very p rofessional", and it w as noted that he "seem ed to have all the proced u res d ow n pat." The pilot's last pilot proficiency check (PPC) on the Island er w as on 30 Ap ril 1993. H is m ost recent Transp ort Canad a (TC) PPC and instru m ent renew al rid e w as on a Pip er PA-31 N avajo, on 25 N ovem ber 1993. The pilot had previou sly flow n Island er aircraft for a form er em p loyer in northern British Colu m bia. H e com m enced em p loym ent w ith Arctic Wings and Rotors in Ap ril 1993. Accord ing to the aircraft journey log-books, he flew ap p roxim ately 406 hours d u ring the p reviou s fou r m onths on the Cessna 185, Cessna 207, Pip er PA-32 Cherokee Six, Pip er PA-31 N avajo, and the tw o Britten-N orm an BN 2A-20 Island ers.

TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N The pilot had not received any on-typ e night training on the BN 2A aircraft. Air N avigation Ord er (AN O) VII, N o. 3, Para 46. (1) (b) (iii) states that the flight training provid ed by an air carrier for a pilot before he serves as a pilot flight-crew m em ber in a m u lti-engine aircraft shall inclu d e, in each type of aerop lane he is to fly, flight instruction and practice in take-offs and land ings by night if he is to fly at night. The pilot's last night flying training w as on 20 N ovem ber 1993 on the PA-31. The pilot had lim ited IFR exp erience, and d id not receive any IFR training on the BN 2A aircraft. N o other aspects of night flying, su ch as the hand ling of em ergencies at night, are singled ou t for m and atory training by this AN O. The pilot rep orted ly had good sleep habits and ad equ ate rest the previou s night. H e had a bronchial asthm atic cond ition that w as treated w ith prescrip tion m ed ication and inhalers as requ ired . The pilot w as respected by his peers and d escribed as a d ed icated , w ell organized , conscientiou s ind ivid u al w ho loved flying, and w as proficient on the aircraft he flew . 1.5.1 Pilot' s W ork Schedule

On the d ay of the accid ent, the pilot's first flight w as from Inu vik to Tuktoyaktu k and retu rn. The d ep artu re from Inu vik w as at 1245; the return flight land ed in Inu vik at 1405. The second flight (the accid ent flight) w as also an Inu vik/ Tu ktoyaktu k/ Inu vik flight w ith a sched u led d ep artu re from Inu vik at 1600. H is flight tim e for the d ay w as 2.2 hou rs, and his d u ty tim e w as ap p roxim ately eight hou rs (d u ty tim e is estim ated to be one hou r before d ep artu re and one-half hou r after retu rn to base). The previou s evening he reported ly w ent to bed at 2230; he arose at 0720 and had breakfast. The previous d ay, 02 Decem ber, he had a flight tim e of 3.1 hours and d u ty tim e of ap p roxim ately 12.5 hours. On 01 Decem ber, he had a flight tim e of 2.9 hours and a d u ty tim e of ap p roxim ately 11 hours. On 30 N ovem ber, he had a flight tim e of 9.7 hours and d u ty tim e of 15 hou rs. The pilot had a flight tim e of 93 hou rs d u ring the last 30 d ays, and 298 hou rs the last 90 d ays. Accord ing to the aircraft jou rney log-books, there w as a total of 13 d ays since 01 Au gu st w hen the pilot d id not fly. H is m ost recent non-flying d ay w as 11 N ovem ber. Days off w ere on an irregular, unsched u led basis and generally su bject to the seasonal w orkload . Days on w hich a pilot w as not sched u led to fly w ere consid ered as d ays off. The resid ence for m ost of the com p any pilots w as located ad jacent to the base of op erations, and p ilots w ere norm ally available to take a flight on very short notice. Occasionally, a pilot w ou ld retu rn to d u ty and com p lete a flight on a d ay he w as not sched u led to fly. Generally, this w as a m u tu ally satisfactory arrangem ent betw een the pilots and the com p any.

1.6

A ircraft Information

Manu factu rer Typ e Year of Manu factu re Serial N u m ber

Pilatu s Britten-N orm an Lim ited BN 2A-20 Island er 1974 398

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FA C TU A L IN FO RM A TIO N

Certificate of Airw orthiness (Flight Perm it) Total Airfram e Tim e Engine Typ e (nu m ber of) Prop eller/ Rotor Typ e (nu m ber of) Maxim u m Allow able Take-off Weight Recom m end ed Fuel Typ e(s) Fuel Typ e Used

Issued 9,391 hr Lycom ing IO-540-K1B5 (2) H artzell H C-C2YK-2CUF (2) 6,600 lb 100/ 130 100 LL

1.6.1

A ircraft Records

The com p any had op erated the aircraft since Febru ary 1993. Prior to that, the aircraft had been leased to another op erator in Inu vik. Exam ination of the aircraft m aintenance record s and logbooks, to the extent possible, revealed no ou tstand ing aircraft d efects. The aircraft journey logbook w as retrieved from the w ater d u ring the on-site investigation and d ried ou t. Som e entries had been m ad e in w ater-solu ble ink, and the entries w ere illegible. The last entry in the aircraft technical log-book w as on 13 October 1994, 116 hours prior to the accid ent. The aircraft and m aintenance record s w ere incom p lete, and it w as not possible to d eterm ine if an unserviceability had been rep orted , rectified , or d eferred , or to d eterm ine w ho had p erform ed the w ork and w hat parts m ay have been repaired or changed . N o d ocu m entation or w orksheets w ere fou nd for w ork com p leted or com p onents changed betw een insp ections. Accord ing to the aircraft jou rney log-book, a 100-hou r inspection w as com p leted on C-GMOP on 07 N ovem ber 1993 at 9,313.0 aircraft hours, and a 50-hour insp ection w as com p leted on 02 Decem ber 1993 at 9,385.1 hou rs. 1.6.2 W eight and Balance Calculations

The aircraft w eight at the tim e of the accid ent w as calcu lated to be ap p roxim ately 6,200 pou nd s, and the centre of gravity (C of G) w as w ithin the prescribed lim its at 23.9 inches aft of d atu m . The C of G lim its are 20.9 to 25.6 inches aft of d atu m . 1.6.3 A ircraft Performance

Pilatu s Britten-N orm an provid ed perform ance d ata based on a test flight and calcu lations for a tem p eratu re of minu s 19 d egrees Celsiu s. At a gross w eight of 6,200 pou nd s, the expected stall sp eed and the m inim u m single-engine control sp eed (VM C A ) w ith the flap s in the take-off position w ou ld be ap p roxim ately the sam e. With the engines at id le rpm (no d ata available for stall sp eed s w ith the engine op erating at high pow er settings), the stall sp eed w ou ld be 48 knots w ith the w ings level, 50 knots in a 20d egree bank, and 57 knots in a 40-d egree bank at a constant altitu d e.

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FA C TU A L IN FO RM A TIO N At low gross w eights, the aircraft w ill reach VM C A before the stall, and at high aircraft w eights, the stall w ill occu r before reaching VM C A . The m anu facturer's rep ort ind icates that if the airsp eed d ecays below the VM C A and the aircraft has not stalled , the resu lt w ill be the start of a slow turn; there w ill be no su d d en catastrophic event.

At 6,200 pou nd s, the estim ated single-engine rate of clim b w ou ld be ap p roxim ately 315 feet p er m inu te (fp m ) at 60 knots, and 360 fp m at 70 knots. Inform ation provid ed by the m anu factu rer ind icates that an ice build u p of 1/ 16 to 1/ 8 inch w ou ld not ad versely affect the flight characteristics of the aircraft und er norm al flying op erations. 1.6.4 Single Engine Procedures

The Britten-N orman Owner' s Handbook, Section 4, Em ergency Op erating Proced u res, states that, in the event of an engine failu re after take-off, the recom m end ed proced u re is as follow s: Ap p ly take-off pow er to both engines, m ixture fu ll rich on both engines, id entify the inoperative engine, select the m ixture control lever to IDLE CUT-OFF, feather the inoperative engine, ensu re that the generator on the op erating engine is ON , allow the airsp eed to build up to 65 knots IAS (best single-engine rate of clim b), select the flaps UP, and ADJUST the rud d er trim as necessary for the clim b.

1.7
1.7.1

M eteorological Information
W eather Synopsis

A w eather analysis for the period covering the occu rrence w as provid ed by the Atm osp heric Environm ent Service, Arctic Weather Centre for the Inu vik and Tu ktoyaktu k regions. A w eak su rface trou gh of low pressu re extend ed from north of Barter Island , Alaska, sou theast throu gh Tu ktoyaktuk to eastern Great Slave Lake. The trou gh w as m oving northeast at about five knots and rem ained w eak. Du ring the m orning and early afternoon, scattered clou d w as observed at Tu ktoyaktu k. At 1300 the clou d base w as 700 feet, and at 1500 the base had risen to 1,100 feet w ith top s at 1,800 feet. At the tim e of the crash, the cond itions rem ained the sam e, w ith light sou thw esterly surface w ind s. 1.7.2 Hourly Observations

The 1700 w eather observation for Tu ktoyaktu k w as aircraft ceiling 1,100 feet overcast, 15 m iles visibility and light snow . The w ind w as from 200 d egrees true at eight knots. The tem p erature and d ew point w ere m inu s 19 d egrees and m inu s 21 d egrees Celsiu s, resp ectively. The altim eter setting w as 29.65 inches of m ercu ry.

The 1700 w eather observation for the Inu vik Airp ort (six m iles sou theast of the tow nsite, at an elevation 210 feet higher) w as balloon ceiling 500 feet overcast, visibility six m iles in ice fog; TRA N SP O RTA TIO N SA FETY BO A RD

FA C TU A L IN FO RM A TIO N tem p eratu re and d ew point, minu s 23 d egrees and m inu s 27 d egrees Celsiu s, resp ectively. The w ind w as calm . The pilot w as provid ed the Inu vik w eather by the FSS sp ecialist w hile taxiing for take-off. Civil tw ilight (d arkness) on 03 Decem ber 1993 occurred at 1623. 1.7.3 Pilot Reports

On land ing at the Tu ktoyaktu k Airp ort, the Island er pilot reported to the FSS that the cloud base w as about 1,100 feet above ground level (agl). Another pilot, ap p roxim ately one hour earlier, had rep orted the cloud base at 1,100 feet and the top s of the cloud layer at 1,800 feet. 1.7.4 V FR Flight at N ight

An overcast night w ithou t a visible horizon provid es few , if any, visu al cu es to the pilot, and is sim ilar to instru m ent meteorological cond itions (IMC), in that the cond itions requ ire the pilot to m ake carefu l reference to the aircraft flight instru m ents. A 1990 TSB rep ort, V FR Flight into A dverse W eather, Section 2.1, VFR Weather Minim a, states that: Canad ian regulations are, in m any w ays, m ore stringent for com m ercial op erations than for private op erations. H ow ever, the criteria for w eather m inim a d u ring d ay VFR op erations for com m ercially-op erated aircraft are the sam e as those governing VFR flight, placing a large nu m ber of fare-p aying passengers at risk. This com m ent ap p lies to an even greater extent to night flight und er VFR. 1.7.5 N ight V FR in Commercial Operations

Pilots fly aircraft either by VFR or by instru m ent flight ru les (IFR). Flight op erations in accord ance w ith VFR at night are safe provid ed that visu al reference and flight visibility are ad equ ate to m anoeu vre the aircraft w ith reference to the horizon and grou nd featu res. Som etim es cues necessary to fly an aircraft at night by ou tsid e references are not available. Even in cond itions of good night visibility, it can be d ifficu lt to fly by visu al reference over d ark or sp arsely lit terrain. When pilots flying at night encou nter cond itions of poor visu al cues, they m u st possess the skill to fly by instru m ents, and m u st be ad equ ately trained for instru m ent flight. Transp ort Canad a's Flight Training M anual (FTM), page 178, ind icates that flying by reference to the grou nd or w ater can be d ifficu lt at night: N ight flying d oes requ ire that you read ju st to a relatively d ifferent environm ent, esp ecially ou tsid e the cockp it. Reference points su ch as the horizon, top ograp hical featu res, and even the grou nd itself, all so vital in establishing aircraft attitu d e by d ay, are ind istinct, obscu re, and som etim es invisible.

Comm ercial flights for aircraft of 12,500 pound s or less cond u cted und er IFR are requ ired to m eet the stand ard s ou tlined in AN O VII, N o. 3 (Standards and Procedures for A ir Carriers Using Small A eroplanes in A ir Transport Operations), Part IV, 39. (3), w hich requ ires tw o pilots, or,

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FA C TU A L IN FO RM A TIO N u nd er Sched u le C, 1(b)4 ap p lication, one pilot and a tw o-axis au top ilot. For a night VFR flight, com m ercial op erators are not requ ired to m eet these stand ard s; how ever, the pilot m u st have an instru m ent rating, and the air carrier m u st fly along airw ays, air rou tes, or com p any rou tes. 1.7.6 Training Environment vs. Operational Environment

Training for a p ilot up to the level of sm all air carrier op erations consists of practice and sim u lating em ergency proced u res. During d u al instru ction or on a flight w ith a training pilot, the pilot is generally prep ared for abnorm alities, and exp ects to have to d em onstrate his ability to d eal w ith em ergency exercises. In contrast, em ergency and abnorm al situ ations in an op erational environm ent are au thentic and usu ally unexp ected by the pilot. The Island er em ergency occu rred at night in m arginal visu al m eteorological cond itions (VMC), w ith few , if any, visu al references, likely w ith no horizon visible. 1.7.7 Training Requirements: A N O V II N o. 3 vs. A N O V II N o. 2

Training requ irem ents for air carriers operating u nd er AN O VII, N o. 3, d iffer from the m ore com p rehensive requ irem ents for air carriers op erating und er AN O VII, N o. 2 (Standards and Procedures for A ir Carriers Using Large A eroplanes). Som e of the sp ecific elem ents that are requ ired und er AN O VII N o. 2 bu t not requ ired und er AN O VII N o. 3 are as follow s: flight training on rejected land ings from 50 feet w ith sim u lated IFR cond itions from 100 feet; d em onstrated know led ge of the rou te being flow n plu s rou te checks and rou te cu rrency; PPCs every six m onths inclu d ing certain assessm ents und er IFR or sim u lated IFR cond itions; d em onstrated pilot ability to fly circling ap p roaches; d em onstrated pilot ability to fly m issed ap p roaches inclu d ing a failu re of a critical engine und er sim u lated IFR or in a sim u lator. Pilots flying a tw in-engine aircraft su ch as the BN 2A, to w hich the requ irem ents of AN O VII N o. 3 ap p ly, are requ ired to have 1.5 hours air tim e of flight training per year on-type. Pilots w ho are not trained und er the m ore com p rehensive requirem ents of AN O VII N o. 2 are m ore likely to encou nter circum stances on op erational flights that they have been unable to practice for in a realistic w ay. N orm ally, a com m ercial pilot of sm all, m u lti-engined aircraft m u st d em onstrate com p etency on each aircraft typ e d u ring an annu al Transp ort Canad a pilot proficiency check (PPC); how ever, Transp ort Canad a m ay grant a carrier an aircraft PPC "grou p ing." Und er the grou p ing system , a pilot w ho su ccessfu lly com p letes a PPC on one aircraft is end orsed on up to tw o other m u ltiengine aircraft typ es. A d ifferent typ e of aerop lane flow n by the pilot shou ld be used each su ccessive year for the cond u ct of the PPC. A PPC group ing d oes not exem p t the operator from cond u cting grou nd and flight training on each type of aircraft. Transp ort Canad a policy letter no. 9 ou tlines the policy for the grou p ing of aircraft: "... The grou p ing of aerop lane typ es and m od els (for PPC pu rp oses) is based up on those having su fficiently sim ilar hand ling characteristics and perform ance." Transp ort Canad a's grou p ing p olicy d oes not requ ire that factors su ch as aircraft system s, lim itations, cockp it layou t, or control configu ration be consid ered prior to grou p ing.

Sch ed u le C - Ter m s, C o n d itio n s a n d Lim ita tio n s A p p lica b le to A u th o r iz a tio n s G r a n ted P u r su a n t to P ar t IV, Su b section 39(3). Sch ed u le C is u sed w h ere a n air car r ier is au th or ized to op era te a m u lti-en g in e a er o p la n e w ith o u t a secon d -in -com m a n d on IFR air tr a n sp or t op er a tion s.

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FA C TU A L IN FO RM A TIO N There is an app roved grou p ing list for aircraft having a Maxim u m Certified Take-Off Weight (MCTOW) of over 7,000 pound s; how ever, there is no sim ilar group ing list for aircraft below MCTOW 7,000 p ou nd s, and only general gu id ance is provid ed for the grou p ing of aircraft. Each regional d irector of Transp ort Canad a Air Carriers branch m ay d eterm ine aircraft grou p ings below 7,000 pou nd s MCTOW. In this accid ent, the op erator had been granted a grou p ing for the BN -2 Island er and the N avajo PA-31; therefore, the PPC flow n by the pilot on the PA-31 the w eek prior to the accid ent fu lfilled his proficiency requ irem ent for the Island er. The BN -2 Island er and the N avajo PA-31 flying characteristics are qu ite d ifferent. The PA-31 N avajo has low w ings, retractable land ing gear and has m u ch higher clim b and cru ise perform ance, and can be controlled d ow n to 78 knots w ith one engine op erating (VM C A ). In contrast, the Island er has high w ings, fixed land ing gear, and the cru ise speed and VM C A are abou t 30 knots slow er than the N avajo's.

1.8

A ids to N avigation

A non-d irectional rad io beacon (N DB) is located on the Tu ktoyaktu k Airp ort, and serves as an ap p roach aid for ru nw ay 09, as pu blished in the Canada A ir Pilot . The aircraft w as equ ip p ed w ith a Trim ble Global N avigation System (GPS). The aircraft w as not equ ip p ed w ith an au top ilot.

1.9

Communications

Comm u nications betw een the pilot and the Tu ktoyaktu k FSS w ere established and satisfactory.

1.10 A erodrome Information


The Tu ktoyaktu k Airp ort is situ ated ad jacent to the ham let of Tu ktoyaktu k. The airp ort reference point elevation is 15 feet asl. The ru nw ay is oriented 088 d egrees (09) and 268 d egrees (27) m agnetic, and is 5,000 feet long by 150 feet w id e, w ith a gravel su rface. It is equ ip p ed w ith ru nw ay end id entification lights (AS) and m ed iu m intensity (ME) runw ay ed ge/ end and threshold (TE) lights. A tw o-bar visu al ap p roach slop e ind icator system (VASIS) is installed at both end s of the runw ay. The lighting equ ip m ent w as rep orted to be op erating norm ally.

1.11 Flight Recorders


The aircraft w as not equ ip p ed w ith a flight d ata record er (FDR) or a cockp it voice record er (CVR), nor w as either requ ired und er existing regu lations.

1.12 W reckage and Impact Information


1.12.1 A ircraft W reckage The aircraft stru ck the ice at an imp act angle of ap p roxim ately 65 d egrees nose d ow n w hile rotating in a clockw ise d irection. The forw ard section of the aircraft, both engines, and the p ropellers broke through the ice and w ere su bm erged in w ater. Both engines w ere torn from the m ou nts, and rem ained attached to the w ing by w ires and engine control cables. The p rop ellers rem ained attached to the engines. The right prop eller w as fou nd in the feathered

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FA C TU A L IN FO RM A TIO N p osition w ith slight d am age to the blad es. The right throttle w as at the id le position, and the right prop eller control lever w as in the feathered position. The left prop eller blad e d am age and tw ist w ere consistent w ith consid erable pow er being prod u ced at im p act. The left throttle and p rop eller levers w ere fou nd in the fu ll throttle and high rpm positions, resp ectively. On im p act, the right w ing lead ing ed ge m ad e an im p rint in the snow , then rotated rearw ard nine feet, as m easu red at the w ing tip . The fu el cells in both w ings ru p tu red and fu el sprayed forw ard in front of the left w ing and aft behind the right w ing, as evid enced by fu el stains in the snow . This ind icates that the aircraft w as rotating in a clockw ise d irection on im p act. The w ings rem ained on the ice surface on top of the partially subm erged fu selage. The em p ennage w as intact, but im p act forces had d riven the horizontal stabilizer forw ard a d istance su fficient to fractu re the ru d d er tab actu ating rod that d rives the ru d d er trim m echanism . The trunnion nu t on the ru d d er tab actuating rod w as found one turn from the u p p er lim it of travel. The lead ing ed ge of the horizontal stabilizer had accu m u lated 1/ 16 to 1/ 8 inch of rim e ice. Becau se of the im p act d am age to the w ings, it cou ld not be d eterm ined w hether or not a sim ilar am ou nt of ice had accu m u lated on the lead ing ed ge of the w ing. 1.12.2 Instrument Examination The TSB Engineering Branch exam ined the airsp eed ind icator and the gyro su ction gau ge to d eterm ine their ind ications at im p act. The instru m ent face of the airsp eed ind icator show ed tw o imp act m arks, one in the range of 126 to 128 knots and the other at ap proxim ately 119 knots. On the gyro su ction gau ge, the left vacu u m red inop erative button (left engine) w as cap tu red behind the d ial face in the retracted position. The right button (right engine) w as in the extend ed position. A m inim u m pressu re of one inch of m ercu ry is requ ired to retract the bu tton to the retracted position. 1.12.3 Instrument Lights The lighting on the right sid e of the instru m ent panel and on the overhead panel w as rep orted ly unserviceable, leaving only the left-sid e instru m ent panel lights. A passenger on the inbou nd trip to Tu ktoyaktu k, w ho w as seated behind the right front seat, reported that the pilot w as using a flashlight to view the right sid e of the instru m ent panel. Extensive d am age to the electrical system preclud ed testing of the lighting system . There w as no record of the d efect in the aircraft jou rney log or m aintenance record s. 1.12.4 Stall W arning The aircraft w as equ ip p ed w ith a p re-stall w arning system to provid e both an aural and visu al signal at a sp eed betw een four and eight knots above the stall sp eed . It w as rep orted that the p re-stall w arning d evice w as unserviceable w hile airborne, bu t w orked on the grou nd w hen tested by m aintenance personnel. There w as no record of the d efect, or of corrective action taken, in the log-books or m aintenance record s. After the accid ent, the d evice cou ld not be tested d u e to the extensive d am age to the lead ing ed ge of the w ing and the electrical system . The stall w arning w as not aud ible on the FSS m agnetic tape record ing. 1.12.5 Engine and Propeller Examination

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FA C TU A L IN FO RM A TIO N The TSB Engineering Branch analyzed the m agnetic tape from the Tu ktoyaktuk FSS to d eterm ine prop eller rp m d u ring the flight. The spectral analysis ind icated that both engines w ere op erating at a prop eller speed of ap p roxim ately 2,355 rp m w hen the pilot reported airborne at 1706:34, and that one engine w as op erating at 2,640 rp m w hen the pilot reported he had an engine problem at 1710:40. Du ring the several transm issions m ad e by the pilot betw een 1710:40 and 1713:03, the prop eller rp m ranged from 2,561 rp m to 2,642 rp m . Both engines w ere d ism antled and exam ined at the Regional w reckage exam ination facility by TSB personnel, w ith an observer from Textron Lycom ing in attend ance. The left engine show ed no evid ence of pre-im p act d am age. N o m echanical d efects w ere found that w ould have prevented the engine or accessories from norm al operation. Exam ination of the left propeller revealed that the blad es w ere in the low pitch (high rp m ) position at im p act. Exam ination of the right engine accessory section found the m ain crankshaft d rive-gear boltthread s stripp ed , and the alignm ent d ow el pin sheared . The crankshaft d rive-gear d rives all the engine accessories, inclu d ing the tw o Bend ix m agnetos, through id ler gears and m agneto d rive gears. Gear teeth w ere m issing from the left id ler gear and m agneto d rive gear. An im p u lse cou p ling flyw eight, m ou nted on the end of the left m agneto, w as fou nd jam m ed against the stop pin m ou nted on the m agneto hou sing.

1.12.6 Engine M agneto The right engine w as fitted w ith tw o Bend ix m agnetos (S6LN -1227). The left m agneto had excessive w ear betw een the flyw eight and axle pin, w hich allow ed the flyw eight to extend and jam against the case-m ounted stop pin. The su d d en stop p age of the m agneto overload ed the second ary gear train for the left magneto, sheared the alignm ent d ow el, and strip p ed the retaining bolt thread s on the m ain crankshaft d rive gear. When the crankshaft d rive gear stopp ed , all the accessories stopp ed , inclu d ing the right m agneto. The im p u lse coup ling consists of tw o flyw eights and sp ring assem blies w hich are part of the m agneto d rive cou p ling (see Figu re 1). Du ring engine starts, the toe of the flyw eight contacts a stop pin on the m agneto housing, preventing the m agneto from turning. As the engine turns, the m agneto d rive gear w ind s the sp ring until it releases and rotates the m agneto rap id ly to send a very intense sp ark to the sp arkplu g. As engine rp m increases, centrifu gal force pu lls the tail of the flyw eight ou tw ard , w hich rotates the toe inw ard , p reventing the toe of the flyw eight from contacting the stop p in.

Figure 1 - Impulse Coupling

10

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FA C TU A L IN FO RM A TIO N The flyw eight pivots on an axle, w hich, if w orn excessively, w ill perm it the heel of the flyw eight to strike the stop pin and eventu ally jam . The clearance betw een the flyw eight and axle pin w as fou nd to be w orn beyond the prescribed lim its of .016 inches. The sid e-p lay betw een the axle pin and the flyw eight that jam m ed w as fou nd to be .046 inches, and betw een the op p osite axle pin and the flyw eight there w as .076 inches. The area betw een the heel and the toe of the flyw eight exhibited an ind entation that corresp ond ed w ith a groove w orn in the stop p in.

1.12.7 Service Bulletins and A irworthiness Directives Bend ix Service Bu lletin (SB) 599B (w hich is ap p licable to this m agneto), issu ed Ju ly 1982, sp ecified that the m agneto insp ection m u st occur after no m ore than 475 op erating hou rs since new or overhau l, and at 500-hour intervals thereafter. The SB provid ed d etailed instru ctions on checking the clearance betw een each im p u lse coup ling flyw eight and each stop pin to d eterm ine axle w ear. The m inim u m sp ecified clearance betw een the axle and flyw eight w as .016 inches. Teled yne Continental Ignition System s SB 599D, issu ed Janu ary 1992, requ ired that the insp ection interval be 100 hou rs. Textron Lycom ing issu ed a m and atory SB 425B, March 1992, that requ ired com p liance w ith Teled yne Continental SB 599D. The SBs w ere m and ated by Airw orthiness Directive (AD) 78-09-07 R3, 17 Janu ary 1983, w hich requ ired all S-1200 series m agnetos incorp orating im p u lse cou p lings to be rem oved , insp ected , and replaced if necessary, in accord ance w ith Bend ix SB 599B or a Fed eral Aviation Ad m inistration (FAA) ap p roved equ ivalent. The AD requ ired that the com p liance tim e, m agneto m ake, m od el, and serial nu m ber be entered in the log-book after the w ork w as accom p lished . N o entries w ere fou nd in the log-book of C-GMOP to ind icate that AD 78-09-07 R3 or the SBs w ere com p lied w ith. A maintenance w orksheet d ated 10 Ju ly 1993 contained an entry that Lycoming SB 425 w as "d one"; how ever, there w as no reference to the comp liance tim e, m agneto m ake, mod el, or serial nu m ber. The history of the failed m agneto could not be d efinitely d eterm ined since the serial nu m ber on it (86510049) w as not consistent w ith the serial nu m ber (8651004) record ed on the engine overhau l sheets. On the m anu factu rer's m etal d ata tag, affixed to the m agneto, the top portion of the last d igit ap p eared to be a "9", bu t w as not clearly id entifiable as a figu re nine. The three other m agneto serial nu m bers w ere traceable back to the last overhau l. Accord ing to the engine tim es since overhau l record ed in the log-books, the m agneto had ap p roxim ately 1,478 hou rs in service w ith no record of an insp ection of the m agneto im p u lse coup ling. Desp ite the am bigu ity in the record keeping on the failed m agneto, all evid ence points to its having been continu ou sly installed on the engine since the overhau l 1,478 hou rs before. 1.12.8 A ircraft Controls Examination

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11

FA C TU A L IN FO RM A TIO N The control su rfaces w ere accou nted for, and all d am age w as attribu table to the severe im p act forces. Control cable continu ity w as checked to the extent possible, and no abnorm alities w ere found . The flap s w ere in the up position at im p act.

The Island er ru d d er trim Figure 2 - Rudder Trim System system is convention al, in that rotating the trim w heel m oves a ru d d er tab w hich d isp laces the ru d d er in the ap p rop riate d irection w hile in flight (see Figu re 2). The ru d d er trim system is op erated by a trim w heel on the cockp it ceiling. A pointer located forw ard of the trim w heel ind icates the ru d d er trim setting. The trim w heel is connected to the ru d d er tab actu ating m echanism in the tail of the aircraft by a chain and cable system . Tu rning the trim w heel counter-clockw ise (as view ed from the pilot seat) m oves the trim tab left and ru d d er to the right; op p osite rotation moves the trim tab to the right and ru d d er left, in flight. The rud d er trim tab is actu ated by a tu bular rod assem bly. The low er end is su p p orted by a bearing hou sing m ou nted on the front of the horizontal stabilizer spar, and an up p er bracket m ounted on the ru d d er sp ar. The top end of the rod is thread ed and rotates in a tru nnion nu t that m oves up or d ow n, d ep end ing on w hich d irection the trim w heel is rotated . The tru nnion nu t is linked to and actu ates the rud d er tab by a lever and rod assem bly. With the rud d er tab in the neutral position, the trunnion nu t is positioned ap p roxim ately m id w ay on the thread ed

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FA C TU A L IN FO RM A TIO N rod end . The trunnion nu t w as found one turn from the up p er lim it of travel, positioning the ru d d er tab to the left. Exam ination of the actuating rod and associated linkages to the ru d d er tab revealed that the low er end of the rod w as bent forw ard and fractu red at the base of the ru d d er, above the low er bearing housing on the horizontal stabilizer. The fractu re su rfaces on the end s of the rod ind icate that the rod w as bent forw ard ap p roxim ately 40 d egrees before fractu ring. The bend ing occu rred as the horizontal stabilizer w as jam m ed forw ard d u ring the im p act sequ ence. 1.12.9 Rudder Trim Operation Island er pilots interview ed after the accid ent related that they frequ ently rotated the trim w heel the w rong d irection, initially, w hen trim m ing for an engine shu td ow n situ ation d u ring practice sessions. H ow ever, the error w as read ily id entified by feed back through the ru d d er p ed al onto the foot. Ru d d er ped al foot pressu re increases if the ru d d er trim w heel is rotated the w rong w ay and , conversely, foot pressure d ecreases if the trim w heel is rotated correctly. They reported that the aircraft requ ired a 1/ 4 to 1/ 3 tu rn on the trim w heel to neutralize the ru d d er p ressure d u ring sim u lated engine-failu re training exercises. Other typ es of aircraft fitted w ith ru d d er trim system s d iffer in w here the trim w heel is located . Aircraft that have the trim w heel located in front of the pilot requ ire the pilot to reach forw ard and rotate the trim the d irection he w ants the aircraft to go. If the pilot w anted to turn the aircraft to the right, he w ould rotate the ru d d er trim w heel clockw ise (from above); if the pilot w anted the aircraft to tu rn to the left, he w ou ld rotate the ru d d er trim w heel cou nter-clockw ise (from above). Because the occu rrence aircraft had the rud d er trim w heel located on the ceiling, above the pilot's head , the w heel had to be grip p ed w ith the palm up ; therefore, rotating the trim w heel cou nter-clockw ise (from below ) tu rned the aircraft right and , conversely, rotating the trim w heel clockw ise (from below ) turned the aircraft left.

1.13 M edical Information


Althou gh m ed ication inhalers for the treatm ent of asthm a w ere fou nd in the pilot's pockets, there w as no evid ence that he w as su ffering from an asthm a attack at the tim e of the crash. There w ere no other natu ral d isease processes id entified that w ou ld have cau sed or contribu ted to the accid ent. The toxicological tests for ethanol and carboxyhem oglobin w ere entirely negative.

1.14 Fire
There w as no evid ence of fire either before or after the occu rrence.

1.15 Survival A spects


The pilot's seat w as not equ ip p ed w ith a shou ld er harness. The im p act d eceleration forces w ere of a m agnitu d e consid ered to be non-su rvivable. Calcu lations of the d eceleration load factors w ere in the range of 55 to 63 G's; how ever, the peak load factors w ou ld have been higher. The em ergency locator transm itter (ELT) activated on im p act, and facilitated locating the w reckage.

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FA C TU A L IN FO RM A TIO N

1.16 Tests and Research


1.16.1 Britten-N orman Test Flight A Britten-N orm an test flight, on a sim ilar Island er, d eterm ined that a foot-force of ap p roxim ately 250 pound s on the left ru d d er w as requ ired to m aintain a head ing at an IAS of 65 to 75 knots w ith m axim u m throttle (2,700 rp m ) on the left engine, the right engine shu t d ow n, right prop eller feathered , and fu ll nose right ru d d er trim ap p lied .

1.17 A dditional Information


1.17.1 Company Operations Arctic Wings and Rotors com m enced op erations in 1991. The com p any received its op erating certificate for a Dom estic N on-Sched u led and International and Sp ecialty Air Service w ith single and m u lti-engine aircraft on N ovem ber 1993. The app roved points w ere Inu vik, Aklavik, and Tu ktoyaktu k, N orthw est Territories. The op erating certificate authorized d ay VFR op erations from the com p any's m ain op erational base at Inu vik Tow nsite, and IFR/ night VFR from the Inu vik Airp ort. At the tim e of the accid ent, the com p any op erated a Cessna 185, a Cessna 207, tw o Britten N orm an Island ers, a Piper PA-31 N avajo, a Piper PA-32 Cherokee Six, and a d e H avilland DH C-3 Single Otter. The comp any w as au thorized by TC, as an Ap proved Maintenance Organization (AMO), to p erform m aintenance, other than sp ecialized w ork, on com m ercially op erated com p any aircraft, in accord ance w ith the A irworthiness M anual Chap ter 573. The M aintenance Control M anual (MCM) w as ap p roved by TC on 12 March 1991. At the tim e of the accid ent the com p any em p loyed tw o licensed aircraft m aintenance engineers (AME). 1.17.2 M aintenance M anagement A TC op erational au d it w as com p leted on 26 N ovem ber 1993. The last TC m aintenance au d it before the occu rrence w as in N ovem ber 1992. Several of the m aintenance au d it find ings related to non-conform ance w ith the proced u res ou tlined in the MCM. Som e of the problem s w hich had been highlighted by the au d it find ings w ere still present d u ring the occu rrence investigation. Maintenance record s w ere fou nd to be incom p lete, and flight-crew -initiated aircraft d efects w ere not being record ed in the aircraft log-books. Recent exam p les of item s reported as not w orking, or item s not being record ed in the aircraft log-book at som e tim e prior to the accid ent flight, are as follow s: the stall w arning w as not fu nctioning in the air; the right sid e instru m ent panel and overhead lights w ere not fu nctioning; and com p liance w ith the ADs and com p onent SBs w as not being entered in the aircraft log-books. MCM Section 4.2 requ ires that the pilot-in-com m and enter into the aircraft journey log any d efect w hich d evelop s so that m aintenance personnel can rectify or d efer the d efect, d ep end ing on w hether the d efect is an airw orthiness or non-airw orthiness item , before fu rther flight. Maintenance record s of recu rring d efects betw een insp ections and correction action taken w ere not com p leted by m aintenance personnel.

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FA C TU A L IN FO RM A TIO N Period ic Britten-N orm an SBs w ere record ed in C-GMOP's log-book; how ever, ap p licable ADs and comp onent SBs w ere not. MCM Section 4.8 requ ires ADs and SBs to be com p lied w ith as d irected by the issu ing au thority, and entered in the ap p rop riate log-books as prescribed by AN O Series VII, N o. 2 and N o. 3, and the A irworthiness M anual, Chap ter 575. A irworthiness M anual AMA 593/ 1 para 3.2 states, "Failu re to com p ly w ith an airw orthiness d irective w ill cau se the Certificate of Airw orthiness to be ou t of force and m ake it an offence to fly the aircraft." Record s of the TC au d its w ere exam ined to d eterm ine w hy som e au d it find ings had not been corrected . It w as noted that the op erator had comp leted the Corrective Action section of the N on-Conform ance Find ing Form s to ind icate that shortcomings had been corrected . At the tim e of the investigation, the corrective action had not taken place. TC has cond u cted an au d it since the accid ent, in Febru ary 1994. 1.17.3 Pilot Duty Times AN O VII, N o. 3, 42.1 prescribes the m axim u m flight tim e, m axim u m flight d u ty tim e, and m inim u m rest period for flight crew m em bers as follow s: (4) The m axim u m flight tim es for a flight crew m em ber are (a) 120 hou rs of flight tim e in any period of 30 consecu tive d ays; (b) 300 hou rs of flight tim e in any period of 90 consecu tive d ays; (c) 1,200 hou rs of flight tim e in any calend ar year. The m axim u m flight d u ty tim e for a flight crew m em ber is 15 hou rs in any period of 24 consecu tive hou rs. ...a m inim u m rest period that allow s flight crew to obtain (a) ad equ ate rest prior to flight d u ty tim e, calcu lated by taking into account the num ber and typ e of flight crew d u ties that preced e and follow the rest period ; and (b) at least one rest period of not less than 24 consecu tive hours (i) once each seven d ay p eriod , or (ii) 13 tim es w ithin each calend ar qu arter. Pilot Fatigue

(5)

(9)

1.17.4

A 1986 report by the Canad ian Aviation Safety Board , (CASB) entitled Fatigue-Related A ccidents and Crew Flight Time and Duty Limitations, fou nd that, of any category of fixed -w ing op erations, com m ercial charter op erators had the highest average 90-d ay and 30-d ay flight tim es. The rep ort id entifies tw o form s of fatigu e: acute and chronic. Acu te fatigu e resu lts from intense flying activities over a relatively short period w hich usu ally involves m u ltip le tasks rep eated regularly. Chronic or long-term fatigue is d efined as fatigue resu lting from the accu m u lation of long flight and d u ty tim es acqu ired over an extend ed period .

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FA C TU A L IN FO RM A TIO N Accord ing to the CASB stu d y, pilot fatigu e can, after an em ergency or abnorm ality is d etected , lead to errors in ju d gem ent. 1.17.5 Transfer Errors

A pilot w ho is cu rrent on d ifferent aircraft typ es could be p rone to the m isap p lication of p roced u res or habits from one type to the next, or the incorrect op eration of controls if the control op erates d ifferently; these errors are m ore com m only know n as "transfer" errors. Transfer errors are m ore likely w hen a p erson is operating u nd er stressors su ch as fatigu e, or em ergency situ ations.

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A N A LYSIS

2.0 A nalysis
2.1 Introduction

The analysis w ill focu s on m aintenance m anagem ent, the engine failu re, the aircraft altitud e and position at the tim e of engine failu re, the pilot's reactions, fatigu e, the aircraft ru d d er trim , the loss of control, and pilot training.

2.2

M aintenance M anagement

Some of the d eficiencies id entified d u ring the 1992 TC au d it w ere ap p arent d u ring the occu rrence investigation. Aircraft d efects w ere not being consistently record ed in the aircraft log-books; nor w ere there record s to show the statu s of recurring d efects betw een insp ections. Com p liance w ith ADs and com p onent SBs w as not being entered in the aircraft log-books as requ ired und er AN O VII, N o. 2 and N o. 3, and the A irworthiness M anual, 575. H ad the m agneto im p u lse cou p ling insp ection been com p leted as requ ired by AD 78-09-07 R3, the w ear patterns cou ld have been d etected and rectified before the m agneto failed . Althou gh TC au d its had id entified such shortcom ings and the com p any had reported corrective action, m any of the shortcomings w ere still present at the tim e of the accid ent.

2.3

The Engine Failure

The m agneto im p u lse coup ling flyw eights w ere w orn beyond the prescribed lim its. When the flyw eight jam m ed against the stop pin, the second ary gear train failed and the engine stop p ed abrup tly.

2.4

A ltitude and Position on Departure

The altitu d e and position of the aircraft w hen the pilot encou ntered the engine problem cou ld not be d eterm ined w ith certainty. The pilot d id not report his altitu d e d u ring the transm issions w ith the FSS. On the inbou nd trip from Inu vik, the pilot rem ained below the clou d base and , if he follow ed his past flying habits, he likely w ould have rem ained below the 1,100-foot cloud layer for the retu rn trip . The thin layer of rim e ice on the tail of the aircraft could have accu m u lated either inbound to Tu ktoyaktu k, or on the d ep artu re. The possibility also exists that the pilot cou ld have inad vertently entered clou d w hile hand ling the em ergency.

2.5

Pilot Reactions

Tw o scenarios w ere stud ied to help und erstand w hy the pilot w as unsu ccessfu l in flying the aircraft back to the airp ort on one engine. There w as no w ay to d eterm ine w hich of the tw o scenarios is m ore likely; how ever, it is clear from the evid ence that the aircraft w as not in controlled flight w hen it hit the ice.

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A N A LYSIS The first scenario exam ines the possibility that the pilot clim bed into or above the clou d layer. If this w ere the case, the low er clou d bases at Inu vik w ou ld likely have necessitated an IFR ap p roach to the Inu vik Airp ort, after w hich the pilot could have continu ed VFR to the tow nstrip . While the pilot held an IFR rating, the aircraft w as not equ ip p ed w ith an au topilot and , since there w as only one pilot on board , IFR w ou ld have contravened AN O VII, N o. 3. The second scenario exam ines the possibility that the pilot rem ained VFR below the clou d s. The lights from the Tu ktoyaktu k Airp ort and ham let w ou ld have been behind him . In this case, he w ou ld have had few visu al references and little or no horizon to provid e attitu d e reference. If he w as successfu l in tu rning the aircraft tow ard the airp ort, w ith the reported 15 m iles visibility, the lights should have becom e visible. If he turned the aircraft using the ground lights as a visu al reference, and if he w as, at the sam e tim e, preoccu p ied w ith carrying ou t the engine failu re em ergency proced u res, he could have become d isoriented and lost control of the aircraft. H ow ever, it cou ld not be d eterm ined how m u ch of the tu rn back to the airp ort w as accom p lished . Given the existing cond itions and the fact that the pilot w as instru m ent rated , it is conclu d ed that he w ou ld have referred to the aircraft flight instru m ents w hile hand ling the em ergency, and probably the GPS and / or the Tu ktoyaktu k N DB for d irectional inform ation. 2.5.1 Fatigue

The pilot rep orted ly had good sleep habits, and had ad equ ate rest the previous night. H is d u ty d ay and flight tim es on the d ay of the accid ent w ere w ithin established lim its. H ow ever, accord ing to the aircraft log-books, his m ost recent non-flying d ay w as 11 N ovem ber, 22 d ays p rior to the accid ent. During the last four-m onth period there w ere 13 d ays w hen he d id not fly. AN O VII N o. 3 sp ecifies one rest period of at least 24 hours in each seven-d ay p eriod , or 13 tim es each calend ar quarter. Typ ically, sm all air carriers d o not have a clearly d elineated policy that d istingu ishes betw een "rest d ays" and non-flying d ays. Frequ ently, pilots m ay not be sched u led to fly on a certain d ay, bu t are available if need ed for flying and / or related d u ties. It could not be d eterm ined if the pilot's w ork sched u le d u ring the last four m onths led to som e d egree of fatigu e w hich cou ld have affected his ju d gem ent and reactions to the em ergency.

2.6
2.6.1

A ircraft
Stall W arning and Instrument Lighting

It cou ld not be d eterm ined to w hat extent, if any, the ap p arent unserviceability of the stall w arning and the cockp it lighting affected the pilot's perform ance. H ow ever, if he need ed to refer to the rud d er trim ind icator on the overhead panel, it w ou ld have been d ifficu lt to read the ind ication if he w as not using his flashlight. 2.6.2 Single-Engine Procedures/Performance

The throttle and propeller controls w ere found in a p osition that w ould ind icate that the pilot p rop erly id entified the failed engine and follow ed the em ergency engine shu td ow n proced u re.

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A N A LYSIS Accord ing to the m anu factu rer's calcu lations, at a gross w eight of ap p roxim ately 6,200 pound s (400 pou nd s below the m axim u m gross w eight), and a C of G of ap p roxim ately 23.9 inches aft of d atu m , the aircraft w ou ld have been cap able of retu rning to the airp ort on one engine. Based up on inform ation received from the m anu factu rer concerning aircraft perform ance in icing cond itions, it is conclu d ed that 1/ 16 to 1/ 8 inch of ice on the lead ing ed ge of the w ings and the horizontal stabilizer w ou ld not have played a significant role in the loss of control. 2.6.3 Rudder Trim

With the right engine inop erative and the left engine op erating, the aircraft w ou ld have a tend ency to yaw and roll into a tu rn to the right. The pilot w ou ld have had to app ly constant foot pressu re on the left ru d d er to stop or lim it the yaw and roll. To relieve the foot pressu re on the ru d d er p ed al, the pilot w ould norm ally rotate the ru d d er trim w heel in the ap p ropriate d irection. N orm ally p ilots rely on feed back throu gh the ap p rop riate ru d d er p ed al onto the foot to confirm w hether they are ap p lying ru d d er trim in the ap p ropriate d irection. This m ethod of control feed back is reliable if the aircraft is in level flight, but can be m islead ing if the aircraft is alread y in a tu rn w hen the trim selection is m ad e. It is not know n w hy the pilot d id not correctly interp ret the ru d d er feed back; how ever, the evid ence su ggests that he rotated the trim w heel in the d irection that w ou ld yaw and roll the aircraft to the right rather than left. With the trim w heel m ou nted on the ceiling, above the pilot's head , it is m ore d ifficult to d eterm ine w hich w ay to tu rn the trim w heel. The investigation attem p ted to d eterm ine w hat effect, if any, being cu rrent on five aircraft types, one of w hich had a ru d d er trim w hich w as m ou nted on the overhead panel, m ight have had on any tend ency to m ake an incorrect trim selection. While no d irect link cou ld be established , intu itively one w ould exp ect that this situ ation w ould increase the likelihood of m aking an incorrect trim selection on the BN 2A, esp ecially w hen und er the stress of resp ond ing to an engine failu re. Since other Island er p ilots, interview ed after the accid ent, related that they frequ ently rotated the trim w heel in the w rong d irection initially w hile trim m ing for an engine shu td ow n d u ring practice sessions, the installation d esign itself is p robably creating som e confu sion. Once the pilot m ad e an incorrect trim inp u t and d id not recognize the error, possibly becau se he m ay have been preoccu p ied w ith other tasks, he cou ld have attributed the aircraft's right tu rning/ rolling m ovem ent to thru st created by the op erating left engine and an inop erative right engine. As the airsp eed d ecreased , the ru d d er w ould have become less effective and the tu rning tend ency greater; if su bsequ ent trim ap p lications continu ed in the w rong d irection, eventu ally the aircraft w ou ld have rolled to the right and / or stalled . 2.6.4 The Loss of Control

The Britten-N orm an test flight rep ort d em onstrated that, to m aintain head ing, ap p roxim ately 250 pound s of foot/ leg pressu re w as requ ired on the left rud d er p ed al to overcome the com bined forces of a m istrim m ed ru d d er and asym m etric thru st created by the op erating left engine and failed right engine. If the foot force on the ru d d er w as relaxed and ailerons w ere u sed to cou nter the right roll, there w ou ld have been a large increase in d rag, a d ecrease in airsp eed and clim b cap ability, and a loss of control.

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A N A LYSIS The w reckage im p act marks ind icated that the aircraft w as rotating to the right on im p act w ith the snow -covered ice surface.

2.7

Pilot Training and W orkload

The pilot had flying exp erience typ ical of pilots w ho fly for sm all com m ercial op erators. H e had com p leted the norm al period ic training and proficiency checks requ ired by his com p any; how ever, he d id not receive on-type night training as requ ired by TC. Consid ering the w orkload d em and s by this typ e of em ergency on a pilot flying alone, it is qu estionable w hether the 1.5 hou rs per year of training requ ired by TC's AN O VII, N o. 3 w ou ld have ad equ ately p rep ared the pilot for the situ ation. Transp ort Canad a's policy allow s the grou p ing of aerop lanes w hich have sim ilarities in hand ling and perform ance. H ow ever, the BN -2 Island er and the PA-31, w hich w ere so grou p ed , have su bstantially d ifferent hand ling and perform ance characteristics. There are fu nd am ental d ifferences in cockp it layout and its system s. Therefore, it is unlikely that a d em onstrated proficiency on one of these aircraft typ es w ou ld ensu re proficiency on the other. The recent prep aration for and com p letion of the PPC on the N avajo m ay have contribu ted to a "transfer error" by reinforcing a ru d d er trim m ing action inapp rop riate to an engine failu re in an Island er. For com m ercial m u lti-engine IFR operations, AN O VII, N o. 3, requ ires tw o pilots, or one pilot and a tw o-axis au top ilot. These requ irem ents recognize the m ore d em and ing natu re of aircraft control by reference to instru m ents d u ring period s of peak w orkload . N ight VFR flight over featu reless terrain and w ithou t a visible horizon--the environm ent for the accid ent flight--is at least as d em and ing of instru m ent flying skills.

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C O N C LU SIO N S

3.0 Conclusions
3.1
1. 2.

Findings
The pilot w as licensed in accord ance w ith existing regu lations. The right engine lost all pow er w ithin four m inu tes after the aircraft took off, w hen the left m agneto im p u lse cou p ling jam m ed . The m agneto im p u lse coup ling flyw eight-to-axle clearance w as found to be w orn beyond the m anu factu rer's prescribed lim its. There w as no evid ence fou nd that Bend ix SB 599B or AD 78-09-07 R3, requ iring m agneto insp ection at 500-hour intervals, had been comp lied w ith. Period ic Britten-N orm an SBs w ere record ed in C-GMOP's log-book; how ever, ap p licable ADs and com p onent SBs w ere not. A irworthiness M anual AMA 593/ 1 states that w hen an AD is not com p lied w ith, the Certificate of Airw orthiness is not in force. Shortcom ings id entified by a 1992 TC m aintenance au d it w ere still present at the tim e of the accid ent. The ru d d er trim m echanism w as found in the nearly fu ll-right rud d er p osition, op p osite to the d irection requ ired for a right engine failu re. The foot force requ ired on the left rud d er p ed al to overcome the combined forces of the ru d d er trim m ed to the right and right engine d rag w as d em onstrated to be ap p roxim ately 250 pou nd s. The ice accu m u lation on the aircraft w ou ld not have played a significant role in the loss of control. The pilot had not received the on-typ e night flying training requ ired by AN O VII, N o. 3. Becau se of the absence of visu al cu es at the tim e of the engine failu re, it is likely that the p ilot had to fly the aircraft by reference to flight instru m ents. Consid ering the w orkload d em and on a single pilot w hen d ealing w ith this typ e of em ergency at night, the 1.5 hou rs per year of training requ ired by Transp ort Canad a is consid ered inad equ ate. While it cannot be d eterm ined that fatigu e contribu ted to this accid ent, the pilot's recent w ork sched u le w as cond u cive to fatigu e. The crash im p act forces w ere not survivable. The ELT fu nctioned and facilitated in locating the aircraft.

3.

4.

5.

6.

7.

8.

9.

10. 11.

12.

13.

14. 15.

3.2

Causes

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C O N C LU SIO N S A m agneto im p u lse coup ling, w orn beyond the prescribed lim its, resu lted in the failu re of the right engine. Follow ing the engine failu re, the pilot m istrim m ed the ru d d er and w as unable to m aintain control of the aircraft.

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SA FETY A C TIO N

4.0 Safety A ction


4.1
4.1.1

A ction Taken
M agneto Inspection

In March 1994, the TSB forw ard ed an Aviation Safety Ad visory to TC regard ing m agneto insp ection and m aintenance requ irem ents. In resp onse, TC sent a letter to the FAA qu erying w hether AD 78-09-07 R3 w ould be am end ed to inclu d e the m ore stringent period ic insp ection requ irem ent of SB 599D. There has been no rep ly to d ate. This m atter w as also featu red in TC's A viation Safety M aintainer new sletter, issu es 3/ 94 and 1/ 95. 4.1.2 M andatory Service Bulletin M S645

On 04 Ap ril 1994, Teled yne Continental issu ed Mand atory Service Bu lletin MSB 645, w hich su p ersed ed SB599D. The reason for the bu lletin w as to d ecrease operational w ear rates on im p u lse coup lings and to p revent engine stopp age. The bu lletin requ ires 100-hour insp ections of riveted im p u lse coup lings. Coup lings w hich d o not m eet the d etailed coup ling insp ection criteria are to be replaced w ith new snap ring assem blies. 4.1.3 Regulatory A udits and Surveillance

Analysis and inform ation from this and 18 other accid ents led to the id entification of shortcom ings in the regulatory overview process of air carriers. In particu lar, it w as fou nd that TC's au d its sometim es lacked d ep th, and that the verification of corrective action follow ing the au d its w as sometim es inad equ ate. Therefore, the Board recomm end ed that: The Dep artm ent of Transp ort am end the Manu al of Regu latory Au d its (MRA) to p rovid e for m ore in-d ep th au d its of those air carriers d em onstrating an ad verse trend in its risk m anagem ent ind icators; (A94-23, issu ed Decem ber 1994) The Dep artm ent of Transp ort ensu re that its insp ectors involved in the au d it process are able to ap p ly risk m anagem ent m ethod s in id entifying carriers w arranting increased aud it attention; (A94-24, issu ed Decem ber 1994)

The Dep artm ent of Transp ort d evelop , as a priority, a system to track au d it follow -up actions; and (A94-25, issu ed Decem ber 1994) The Dep artm ent of Transp ort im p lem ent both short and long term actions to place greater em p hasis on verification of requ ired au d it follow -u p action and on enforcem ent action in cases of non-com p liance.

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SA FETY A C TIO N (A94-26, issu ed Decem ber 1994) In resp onse to these recom m end ations, TC has ind icated that both recom m end ations A94-23 and A94-24 w ill be taken into consid eration d u ring am end m ents to the MRA. Also, TC w ill ensu re that the Au d it Proced u res training p rogram for insp ectors takes into account recom m end ation A94-24 so that risk m anagem ent m ethod s are clearly und erstood and ap p lied . TC's rep ly to recomm end ations A94-25 and A94-26 ind icates that the MRA w ill be review ed to ensu re that clear policy d irection is given to ensu re that effective au d it follow -u p system s are in p lace. Fu rtherm ore, TC intend s to have an enhanced N ational Aviation Com p any Inform ation System (N ACIS) op erational soon to track au d it follow -u p on a national basis. In the interim , a p olicy d irective w ill be issu ed to regions to requ ire a review of resp ective regional follow -up system s.

4.2
4.2.1

A ction Required
N ight V FR Commercial Operations

Comm ercial flights for aircraft of 12,500 pound s or less cond u cted und er IFR are requ ired to have either a crew of tw o p ilots, or one pilot and a tw o-axis au top ilot. These requ irem ents recognize the d em and ing natu re of m aintaining aircraft control and situational aw areness w ith reference to instru m ents only. N ight VFR flights over featu reless terrain and w ithou t a visible horizon also d em and instru m ent flying skills. As su ch, the regu latory requ irem ents for com m ercial night VFR op erations contain som e safegu ard s; e.g., in consid eration that the flight m ay tem p orarily encou nter instru m ent m eteorological cond itions or poor am bient lighting, the pilot m u st be instru m ent rated ; and to m inim ize the risk of collisions w ith terrain or obstacles, the flights m u st be cond u cted along airw ays, air rou tes, or ap p roved com p any rou tes. H ow ever, these requ irem ents d o not ad d ress the ad d ed pressures placed on aircrew in severely d eteriorated flight cond itions or em ergency situ ations. Legally, night VFR comm ercial flights m ay be cond u cted w ith only one pilot and w ith no au top ilot. The aircraft in this occu rrence w as certified for single pilot use in VFR op erations, d ay or night; yet, this sam e aircraft used for com m ercial flight op erations und er IFR w ou ld have requ ired tw o pilots. In the Board 's view , coping single-hand ed ly w ith w eather d iversions or an em ergency d u ring a d ark night VFR flight w ould be very d em and ing, comp arable to trying to hand le these situations single-hand ed ly on an IFR flight. H ow ever, on an IFR flight, another p ilot w ou ld provid e an ad d ed safety factor. The d ifferences in d isp atching requ irem ents for crew and in equ ip m ent requ irem ents betw een com m ercial VFR and IFR flights are an econom ic consid eration for op erators. With VFR singlep ilot crew ing, m anp ow er costs are low er; and the "nil" requ irem ent for an au top ilot red u ces equ ip m ent and servicing exp enses. Also, w ith VFR flight planning requ irem ents for alternate airp orts and fu el reserves being less restrictive than the IFR requ irem ents, the op erator cou ld have greater flexibility in m eeting the rou ting and sched u ling d em and s of his custom ers. Althou gh econom ic pressu res are a factor to be consid ered by op erators in the passengercarrying bu siness, from the fare-p aying pu blics point of view , the level of safety shou ld not be a fu nction of the typ e of op eration (i.e., VFR or IFR) or the tim e of d ay.

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SA FETY A C TIO N Aircrew in single-p ilot comm ercial night VFR op erations d o not have the sam e level of safety back-u p as their IFR counterp arts in term s of equ ip m ent and crew requ irem ents to safely cope w ith unforeseen situ ations. The Board is concerned that su ch night VFR flights d o not afford the fare-p aying pu blic a level of safety equ ivalent to that on sim ilar flights und er IFR. Therefore, the Board recomm end s that: The Dep artm ent of Transp ort raise the regu latory requ irem ents for the cond u ct of comm ercial passenger-carrying night VFR flights to provid e a level of safety comp arable to that provid ed on IFR flights w ith sim ilar aircraft. A95-16 4.2.2 Training

4.2.2.1 N ight Training In ord er to carry passengers at night on m u lti-engine aircraft, an op erator is requ ired to provid e sp ecific on-typ e night training for com p any p ilots. The pilot in this occu rrence had not received this training; nor had this shortcom ing been d etected by Transp ort Canad a insp ectors d u ring the au d it of the comp any's op eration one m onth prior to the accid ent.

In Janu ary 1993, follow ing the investigation of a tw in-engine tu rbo-p rop aircraft accid ent at Moosonee (TSB rep ort A90H 0002) in w hich neither of the pilots involved had received the requ ired night training and the regional Transp ort Canad a insp ectors had not observed that the training had not been cond u cted , the Board recomm end ed that: The Dep artm ent of Transp ort valid ate its cu rrent proced u res for checking that air carriers provid e the requ ired m u lti-engine night training. (A93-05, issu ed Janu ary 1993) TC respond ed in Au gu st 1993 that the M anual of Regulatory A udits (MRA) (pu blished since occu rrence A90H 0002) d irected the au d it staff to check the com p anies' flight training p rogram m es. In ad d ition, TC notified the regional Air Carrier staff of this m atter and instru cted its Qu ality Assu rance Review team to ensu re that the verification of night training d id occur. This occu rrence is another exam p le of a night accid ent in w hich the pilot had not received the requ ired night training. N otw ithstand ing Transp ort Canad a's continu ing efforts to strengthen its processes for regu latory au d it and su rveillance, som e com m ercial pilots are still not receiving the requ ired night training. Since the skills requ ired for safe night op erations requ ire reinforcem ent through period ic night training, the Board recomm end s that: The Dep artm ent of Transp ort cond u ct a sp ecial one-tim e aud it to confirm that com m ercial pilots involved in night m u lti-engine op erations are receiving the requ ired night training. A95-17 While TC aud it proced u res continu e to m iss inad equ acies in the night training of com m ercial p ilots, it is recognized that TC insp ectors cannot be continu ou sly on site to ensu re that

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SA FETY A C TIO N op erators are provid ing this training. Ind ivid u al op erators m u st be held accou ntable for any failu re to provid e m and atory training. Therefore, the Board recomm end s that: The Dep artm ent of Transp ort evalu ate the effectiveness of its current practices for d ealing w ith those op erators w ho are not provid ing m and atory training for pilots. A95-18 4.2.3 A ircraft Grouping for Pilot Proficiency Checks (PPC)

TC had au thorized the grou p ing of the Island er and the N avajo aircraft for PPCs for this op erator. (The grou p ing of these tw o aircraft has reported ly been au thorized at other carriers as w ell.) The policy regard ing the grou p ing of aircraft for PPCs requ ires only that the aircraft be grou p ed accord ing to perform ance and hand ling characteristics. H ow ever, significant d ifferences ap p arently exist in both the hand ling characteristics and perform ance of the N avajo and Island er aircraft. Differences in the d irection of ap p lication of the ru d d er trim betw een the tw o aircraft m ay have been critical in this accid ent. The Board und erstand s the d esirability for op erators to grou p aircraft for the cond u ct of PPCs. H ow ever, the Board believes that guid elines for the group ing of aircraft mu st ensu re that a p roficiency check on one aircraft of a group w ill consistently be an accu rate ind icator of pilot p roficiency on other aircraft in the sam e group . Inap p ropriate group ings m ay lead the pilot, operator, and flight exam iner to believe that the pilot's ability to hand le all aircraft in the group is better than it actu ally is; su ch pilots w ill be vu lnerable to encountering situ ations beyond their d em onstrated cap abilities. Therefore, the Board recom m end s that: The Dep artm ent of Transp ort confirm the su itability of all existing PPC aircraft grou p ings such that proficiency on one type is truly rep resentative of all aircraft in the grou p ing. A95-19 A pilot w ho is cu rrent on several aircraft typ es is prone to ap p lying the sp ecific proced u res or p ractices for one type to another; this inclu d es the possible incorrect op eration of controls if the control fu nctions are significantly d ifferent from one aircraft to another. Su ch errors in the p erform ance of an op eration or p roced u re are know n as "transfer errors." Ind ivid u als are m ore su scep tible to transfer errors d u ring period s of stress cau sed by high w orkload s. The incorrect app lication of rud d er trim d u ring an engine failu re in a m u lti-engine aircraft w ou ld be a typical transfer error if the proced u re to ap p ly the trim varied significantly betw een d ifferent aircraft on w hich the pilot w as cu rrent. Differences in cockpit layou t, in the op eration of flight and engine controls, in the m ajor aircraft system s, and in the critical em ergency proced u res cou ld p rom ote transfer errors. To m inim ize aircrew su sceptibility to m aking transfer errors, aircraft grou p ings shou ld be based on m ore than general sim ilarities in aircraft hand ling and p erform ance. Therefore, the Board recomm end s that: The Dep artm ent of Transp ort revise the guid elines for group ing aircraft for PPCs to take into accou nt the susceptibility to transfer errors by aircrew . A95-20 Transp ort Canad a has established an ap p roved list of group s of aircraft for aircraft above 7,000 p ound s Maxim u m Certified Take-Off Weight (MCTOW). It is und erstood that a

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SA FETY A C TIO N com p rehensive analysis of the d ifferences and sim ilarities betw een the aircraft in each group w as cond u cted to ensu re the com p atibility of aircraft. Su ch an ap p roved list is not available for com m ercial aircraft below 7,000 pound s MCTOW. Ad hoc group ings of aircraft based on su p erficial sim ilarities betw een aircraft can lead to fu nd am entally d issim ilar aircraft being group ed together (e.g., N avajo and Island er), creating cond itions cond u cive to transfer errors u nd er high cockp it stress. Therefore, the Board recomm end s that: The Dep artm ent of Transp ort, w here practicable, establish an ap p roved list of aircraft grou p ings for PPCs of aircraft having a Maxim u m Certified Take-Off Weight (MCTOW) of und er 7,000 pou nd s. A95-21 This report concludes the Transportation Safety Board' s investigation into this occurrence. Consequently, Chairperson John W . Stants and member Z ita Brunet authorized the release of this report on 18 October 1995, pending ratification by the full Board.

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A P P EN D IC ES

A ppendix A - Flight Locale - C-GM OP

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A P P EN D IC ES

A ppendix B - M ap of Flight Path - C-GM OP

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A ppendix C - List of Supporting Reports


The follow ing TSB Engineering Branch reports w ere com p leted : LP LP LP LP 173/ 93 - FSS Record ing Analysis; 16/ 94 - Instru m ents Exam ination; 6/ 94 - Crankshaft Bolt; and 63/ 94 - Im p act Load s.

These rep orts are available up on requ est from the Transp ortation Safety Board of Canad a.

A P P EN D IC ES

A ppendix D - Glossary
AD agl AME AMO AN O AS asl ATPL C of G CASB CVR ELT FAA FDR fp m FSS FTM G GPS hr IAS IFR IMC lb LL MCM MCTOW ME mi MRA MST N N ACIS N DB PPC rp m SB SE TC TE TSB UTC VASIS VFR VMC VM C A W ' Airw orthiness Directive above grou nd level aircraft m aintenance engineer ap p roved m aintenance organization Air N avigation Ord er ru nw ay end id entification lights above sea level Airline Transp ort Pilot Licence centre of gravity Canad ian Aviation Safety Board cockp it voice record er em ergency locator transm itter Fed eral Aviation Ad m inistration flight d ata record er feet per m inu te Flight Service Station Flight Training Manu al G load factor global positioning system hou r(s) ind icated airsp eed instru m ent flight ru les instru m ent m eteorological cond itions p ou nd (s) low lead Maintenance Control Manu al m axim u m certified take-off w eight m ed ium intensity runw ay lighting m ile(s) Manu al of Regu latory Au d its m ou ntain stand ard tim e north N ational Aviation Com p any Inform ation System non-d irectional beacon p ilot proficiency check revolu tions per m inu te service bu lletin sou theast Transp ort Canad a threshold lights Transp ortation Safety Board of Canad a Coord inated Universal Tim e visu al ap p roach slop e ind icator system visu al flight ru les visu al m eteorological cond itions m inim u m single-engine control speed w est m inu te(s) TRA N SP O RTA TIO N SA FETY BO A RD

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A P P EN D IC ES '' second (s) d egree(s)

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