Aviation Safety

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Postby lazair » Tue Oct 14, 2003 6:26 pm

QUOTE (lazair @ Oct 14 2003, 07:24 PM)
QUOTE (lazair @ Oct 14 2003, 07:24 PM)
QUOTE (lazair @ Oct 14 2003, 07:22 PM)
Aviation Safety Letter 3-2003  

Recreational Aviation: Missing bolt fatal
(This article was originally published in Aviation Safety Ultralight and Balloon, Issue 2/95)
user posted image

There are numerous models of the Beaver ultralight available on the used market. Since the Beaver factory is no longer in business, it is difficult for the Beaver owners to obtain ongoing maintenance information and spare parts.

The Beaver ultralight was on a local practice flight with an instructor and student on board. At about 500 feet altitude the wing was observed to detach from the aircraft and the occupants lost their lives in the ensuing crash. Findings during the preliminary investigation were that the bolt on the left wing rear attachment point was missing. Reasons for the missing bolt have not been determined. Unless the bolt is found, the exact cause may never be determined.

The following three points on safety are suggested as a result of this tragedy:

Prior to installation, inspect bolts and safety devices that attach wings and tail components to ensure that they match the manufacturer's material specifications. 
Prior to any flight, inspect visible high-stress points such as wings, spars, struts, tail assembly and flight controls for security and correct bolts, lock nuts, safety pins, cotter keys and lockwire as specified by the manufacturer. 
If the wings or other major flight components have been removed for repair or transport, then have a second knowledgeable person inspect the reassembled ultralight for security and properly installed locking devices prior to flight.
There have been a number of very serious ultralight accidents and incidents resulting from carelessness or ignorance of basic mechanical assembly details of these machines. The ultralight community can learn from these occurrences and become more safety conscious as a result.

Aviation Safety Letter 3-2003

Short take on human factors basics
Approximately 80% of aviation accidents are primarily caused by a human error, while the remaining 20% almost always involve a human factors component. The following is the fourth, and last, of a series of short passages from TP 12863E, Human Factors for Aviation—Basic Handbook. We hope this encourages you to look further into this fascinating, and relevant, topic. —Ed.
The Importance of Judgement

Some writers see judgement as the process of choosing which alternative will give the safest outcome in a given situation. However it is defined, we need good judgement in order to fly safely. But there is much more to it than that.

Judgement and Regulations

In aviation, more than any other field we can think of, regulations are based on the assumption that practitioners will interpret them in accordance with their own skill. Though applying at face value to all pilots, the regulations are actually geared to the pilot who is extremely proficient, flying a well-equipped aircraft. Thus, whereas any pilot may be legally entitled to fly a cross-country flight in marginal VFR conditions, it is up to the individual pilot to judge whether such a situation exceeds his or her own personal limits, based on experience and currency.

Likewise, all performance data in the aircraft operating manual are derived from perfect situations. The take-off roll, for example, assumes a hard dry runway in a well functioning aircraft with an engine developing maximum horsepower. In real life, of course, any deviation from this ideal lengthens the required runway distance: if the engine is a little older, if the runway is contaminated with snow or water, or if the tires of the aeroplane are not at the correct pressure, then the numbers in the manuals are not accurate. So, once again, the individual pilot has to interpret the situation and apply judgement in determining what numbers to use. Using the data in the aircraft manual blindly, without interpretation, is likely to prove a bad judgement.

Judgement as the Basis of Aviation
Judgement is important in flying because the pilot is given a great deal of latitude in making decisions. The whole aviation system is based on the assumption that pilots will exercise good judgement in securing the safety of themselves and all others in the system. In other words, the aviation system is based on trust. Pilots are expected to honour the responsibility they have been given. Each time you exercise bad judgement, you are not only endangering yourself and others, but also undermining the very basis of aviation.

Good judgement, therefore, is much more than the means of safety. It is the cement that keeps all aspects of flying together.

Excerpt from TP 12863E Chapter 10, page 145. You can obtain your own copy of this publication by calling the TC Civil Aviation Communications Centre Services at 1-800-305-2059.

Aviation Safety Letter 3-2003

What wires?
by Garth Wallace

My first passenger, that drizzly morning, owned a cottage on a remote lake. He and I were sitting in a four-seat floatplane, which was tied to the dock. The weather had started to lift but we were waiting for more ceiling and visibility before taking off. He talked. I listened.

This was his first time using the air service. “I live in the city, but I come north to my cottage every chance I can get,” he said. “I always drive my car to the marina at the other end of my lake and then go the last five kilometers by motorboat. When I come to town for supplies, I often stop here to watch the airplanes. I decided to charter an airplane some day as a little adventure for myself, so here I am.”

He said he didn’t mind waiting for the weather. He had never flown before and was enjoying being part of the goings-on at the air service. He considered the delay a bonus.

Normally we flew customers to their fishing camps or cottages and returned empty. At the end of their stay we’d fly back empty and pick them up. This did not seem cost-effective at all to this customer, so he had arranged just one flight. I was to fly him to his cottage, drop off his gear and then he was going to fly back to town with me to pick up his car, and finish the trip his normal way. This gave him two airplane rides for the price of one and avoided the cost of another roundtrip flight to bring him out.

The weather soon picked up enough to depart. I signalled the dock boy to cast us off. When we were clear, I fired up the engine and taxied out. My passenger showed an interest in the airplane’s controls and instruments so I explained the basics while circling to warm up the engine. Our load was light. We departed easily.

The customer stayed glued to the window, looking down on the lakes and forest rolling by, throughout most of the trip. He had shown me on the map that his cottage was on the long arm of a large lake. I had never been there before. When we arrived I flew a slow pass over his section of the water before landing. His face lit up when he saw his place from the air. I inspected the long bay for rocks, logs and wire crossings, while my passenger checked out what his neighbours were doing to their properties. The dark water looked deep and clear on that grey morning. I did not see any obstructions. There was no wind so I set up an approach toward the open end of the bay, touched down smoothly and stopped close to my man’s dock.

We unloaded his things and re-boarded for the return flight. It was an easy takeoff. There was no boat traffic, the airplane was light and I had the entire length of the bay and four kilometres of lake beyond. Conversation in flight was difficult over the noise, but I pointed out some of the local landmarks as we flew back to the base.

After landing, the passenger thanked me while we taxied to the dock. He was visibly excited by the flight. “I always wondered if the pilot would fly over or under the wires crossing the bay when I took a plane into my place,” he said.

I didn’t reply. I felt the colour drain from my face. There were no wires crossing the bay; at least I hadn’t seen any.

I contemplated how close we might have come to snagging hydro lines. We must have passed them on the landing and the takeoff. Shivering at the thought, I was late cutting the power on my approach to the dock. The dock boy knew what was going to happen next. The left float whacked the tires along the side and mounted the planks. The airplane stopped at a crazy angle, with the left float almost clean out of the water.

I opened my door and hopped down. The dock boy helped me horse the airplane back into the water. My passenger said nothing but smiled nervously as he climbed out and scurried off to his car. He is the only one who knows how close we came to the wires, but he may never fly again. He thinks that docking a floatplane is dangerous.

The chief pilot talked to me later. “I heard you were rearranging the docks this morning.”

I told him the whole story. “I did everything you taught me about approaching a new destination. I could not see any wires. What else could I do?”

“You could have asked.”

“Asked who?”

“Who knew there were wires?”

Garth Wallace is an aviator, public speaker and freelance writer who lives near Ottawa, Ontario. He has written seven aviation books published by Happy Landings (www.happylanding.com). He can be contacted via e-mail: garth@happylanding.com.

user posted image

Wires, wires, wires…what the floatplane pilot’s
nightmares are made of…

Aviation Safety Letter 3-2003

More lessons learned in 2002...
The following occurrence descriptions were randomly selected from the TSB’s-Class 5 investigations for the year 2002. As you will see, there are very few new accidents. The occurrences have been slightly edited and de-identified, just enough to protect the innocent, the foolish or the simply unlucky aviators. Some locations were left in where needed for proper context.

A Piper PA18-150 had departed Fort Nelson Gordon Field (CBL3), with 2 people on board. On touchdown at an unimproved farm field, the pilot was not satisfied with the speed of the aircraft and decided to abort the landing. Shortly after liftoff, the aircraft struck a power line, control was lost and the aircraft overturned into a small pond. Both occupants sustained minor injuries, and the aircraft was substantially damaged.

Aborting a landing is OK, as long as you have room for it. - Ed.

A Nanchang CJ6A (Yak 18) aircraft was on a local familiarization flight with the pilot/owner occupying the rear seat and his passenger occupying the forward crew position. The aircraft crossed over Osoyoos Lake and commenced a climb toward rising terrain on the east side of the lake. During this climb, the airspeed decreased rapidly. The aircraft made a slow turn to the right and entered a box canyon where it subsequently stalled and crashed. The pilot sustained serious injuries; the passenger was released with minor injuries. The aircraft was destroyed.

Considering the past history of flying into “box canyons,” these two people were lucky. If you fly in mountains, valleys and canyons, you must be twice as vigilant about knowing your aircraft performance capacities. —Ed.

A DHC-2 Beaver amphibious float-equipped aircraft departed the Sudbury airport, in Ontario, and was destined to Lake Temagami. After takeoff, the landing gear was not retracted. Upon touchdown on the water surface at Lake Temagami, the aircraft nosed over and came to rest in an inverted position. Egress from the aircraft was unhampered and the uninjured pilot was picked up by boaters who observed the occurrence.

Amphibious aircraft are wonderful, until
you land on the water with the wheels down.-Ed

A Cessna 180 on floats was landing westbound on the Fraser River at the Pitt Meadows float base. Shortly after the aircraft descended out of the tower controller's view, behind a tree line along the riverbank, an ELT signal was received in the control tower. The left float had dug in upon touchdown and the aircraft nosed-over and eventually became inverted. The two occupants had time to exit the cabin and were rescued uninjured by a water taxi about 40 minutes after the accident. Both occupants had been wearing the lap and shoulder restraint belts, and the pilot was wearing an inflatable coat.

Good example of use of safety and emergency equipment. - Ed.

As a Cessna 206 was about to touch down on a 1 200-ft-long dirt strip, the sun broke through the clouds, blinding the pilot. When vision was restored a few seconds later, the aircraft was poorly positioned and the pilot aborted the landing. The aircraft could not out-climb the uphill slope of the strip, and impacted shrubs and small trees at the end. The aircraft was substantially damaged, and the occupants, who wore the available shoulder harnesses, were uninjured.

A setting sun can seriously affect your vision. See the article on proper sunglasses in this issue of ASL. - Ed.

The crew of a Bombardier CL-415 was taxiing for departure at Pickle Lake, Ontario, for a local firefighting flight. As the aircraft was manoeuvring, its left wingtip struck a standing Bell 205A helicopter, which was parked on the ramp. No injuries resulted. The CL-415 sustained damage to its left wing. The Bell 205A sustained damage to its main rotor system.

Taxiing in tight quarters? If unsure of clearance, use a marshaller. - Ed.

A DHC-2 Beaver on floats was en route from Holinshead Lake to Kashishibog when the pilot encountered deteriorating weather conditions. As the flight progressed, the ceiling became increasingly lower until it was nearly at tree top level. Shortly thereafter the pilot located a cabin at the destination outpost camp. On final approach to the camp, the aircraft struck the water while in a turn, tearing off one float, and it eventually sank. The pilot and four passengers exited the aircraft and attempted to swim ashore. While swimming, one of the passengers went missing and was not located.

Continued flight into deteriorating weather conditions—why? —Ed.

A Piper PA28-180 was en route from Pickle Lake, Ontario, to International Falls, Minnesota. Approximately 16 NM north of the Fort Francis airport, the engine lost power and the aircraft was forced to land on a logging road. Two of the three people on board received minor injuries and the aircraft was substantially damaged. The operator advised that the aircraft had run out of fuel.

Run out of fuel—why? —Ed.

A Cessna 182 aircraft was in level flight at 10 500 ft, preparing for a parachute jump. A jumper was outside the aircraft on the step and holding on to the strut in preparation to jump, when his parachute deployed prematurely, pulling him rearwards off the step. The helmet of the jumper struck the horn of the right-hand elevator, injuring the jumper and damaging the elevator. The right-hand elevator was buckled and torn off the outboard hinge, but the pilot was able to control the aircraft and land safely, noticing only a restriction during the flare. The critically injured jumper was found about eight hours later. user posted image

The reason for the premature opening of the parachute was not in the report. If you fly in support of sport parachuting, look into this with the Canadian Sport Parachuting Association. —Ed.
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