Transportation Safety Board Update

  • December 01, 2010

This meeting was held at 12:00 p.m. at Miller Thomson LLP – 11th Floor, 840 Howe Street in Vancouver, British Columbia.

Guest Speaker

Bill Yearwood


K.N. Burnett acted as Chair of the meeting. The following items were discussed:

  • Annals of Air & Space Law
    Gary Abrams advised the meeting that Volume 35 of the Annals of Air & Space Law were now in the Courthouse Law Library.
  • Other Topics
    Ken Burnett reminded the meeting of the upcoming CBA web course on practice before the Transportation Safety Board which is to take place on December 15, 2010. Most of the members at the meeting indicated they had received notice.
  • Gudzinski Case (Albert QB)
    Ken Burnett gave a brief summary of this case, which was about the refusal of an insurance company to cover the loss of an aircraft sustained by the estate of a pilot who died in a crash. He had his pilot’s license but did not have the medical certificate required for that license. The court’s judgment was on the basis that as it was the insurer’s contract, it was not at liberty to expand the contract to include other conditions other than what it contained. Accordingly the court took the position that as Mr. Gudzinski had the required license at the time of the crash, the fact that he did not have a valid medical certificate did not affect the coverage under the policy and accordingly it held in favour of his estate which was claiming monies for the loss of the aircraft. This case was decided by a Master of the Alberta Court of Queen’s Bench and the case is presently being appealed to the Alberta Court of Appeal.

    At the next meeting of the Section Steve Gill will give a more thorough analysis.
  • Constitutional Cases –Quebec (AG) vs Canadian Owners & Pilots Association [290] SSC (October 15, 2010) and Quebec (AG) vs Lacombe SCC (October 15, 2010)
    David Varty gave a presentation to the meeting regarding the two cases occurring in Quebec where the issue was that paramountcy or the priority of the Federal legislation over provincial legislation or municipal bylaws which attempted to ban the use of aircraft and aerodromes. A copy of Mr. Varty’s presentation is attached to these minutes.

Main Presentation

Bill Yearwood - Regional Manager, Air Investigations, Pacific Region, Canadian Transportation Safety Board

Ken Burnett introduced Mr. Yearwood. Mr. Yearwood is a regular speaker at Section meetings and usually comes every two years.

He indicated to the meeting that he wanted to talk about incidents at Lyall Harbour, Tofino, the crash of the Navaho Chieftain in Richmond and the Convair crash.

The Chair made it clear that Mr. Yearwood’s presentation was on a "without prejudice" basis and that none of his comments could be taken or used against him in respect to any other proceedings or matters involving the Transportation Safety Board ("TSB") or the investigation of any accidents which were currently under their jurisdiction.

He then gave his PowerPoint presentation. He talked about some policy issues the Board was concerned with including commercial operations, potential safety issues and fatal accidents. He reminded the members that a great number of their cases are known as "incidents." In those cases, the TSB does not do full blown investigations, which are usually less likely particularly when the pilot can give them the facts and it is likely to be a Class 5 matter. For example, the incident involving the Comanche accident out of the Penticton Airport did not require a separate investigation as the facts were very clear.

The TSB is using video technology but it still relies on usually tried and true methods of investigations including obtaining hard evidence such as witness statements and other hard evidence.

As an aside, he indicated that as a result of certain recent accidents there had been proposals put out whereby video recorders would put inside the aircraft and perhaps even externally so that if an incident occurred it would be recorded. He also suggested that these videos would be digitally connected on an electronic basis so they would not have to find the aircraft to find the video. Apparently, Bell Helicopters and Euro Helicopters are actively pushing to get this done.

Conair Accident

Mr. Yearwood shared some information on the Conair accident near Lytton. The aircraft that crashed appears to have hit some trees, and subsequently the pilot appears to have lost control. The pilot did an initial release of some of the fire retardant, before the loss of control. He suggested that a possible reason for the crash might have been an optical illusion, which had affected the pilot’s abilities to verify the exact terrain he was in and the horizon. He gave an explanation of an optical illusion in occurring mountainous terrain creating an artificial horizon which could catch an inexperienced pilot. It is not a question of "pilot error" but rather a matter of "human error" and the inability of humans, in certain cases, to effectively determine the horizons.

Bell 214 Crash

TSB examined this particular crash and came to the conclusion that the crash was related to a loss of power. TSB looked at the fuel controls and had them tested in both of Canada and offshore. The TSB conclusions were that a part of cotter pin apparently got into the fuel chamber, which hindered effective fuel flow operations causing the aircraft to lose power.

Grumman Goose Accident at Thormanby Island

This investigation is complete. From what the TSB could determine, because of poor visibility the pilot reacted only when he crossed the beach at Thormanby Island and tried to climb. There was not enough performance to allow the climb to clear the terrain. TSB also did an investigation on the ground to look at evidence of an aircraft clipping trees to see what kind of climb was taking place prior to the crash.

Navaho Chieftain – Richmond

This was a case where TSB believed that this aircraft, which was flying towards the flight path on the north runway at YVR, ran into wake turbulence. Wake turbulence probably caused the aircraft to lose its stability and crash. Visual separation is harder to do at longer distances and at night, it is very difficult. The risks of VFR pilots encountering wake turbulence is higher at night and secondly NavCan do not provide separation for VFR flights. He suggested that if the aircraft had been flying say 200 feet higher along the approach path it would be above the wake turbulence and the problem may have been avoided. He suggested that small aircraft operator’s do not need the 10,000 foot runway length to land and that the more prudent course would be to fly higher than the large aircraft landing and land on the last 5,000 feet of the runway.

Beaver Accident at Lyall Harbour

The TSB examination indicated that the flaps might have been in the "landing" position on take-off. However, this did not have an effect on the aircraft’s takeoff and the crash. The other problem with this crash is that although one passenger survived the others "drowned." TSB has been actively working to get some safety action taking place in all floatplane operations. TSB is now attempting to make sure that there are push out windows for better emergency egress and all persons wear floatation devices.

Tofino Cessna 185 Crash

In this case, the aircraft crashed directly into the ocean at a fairly significant speed. There were no survivors. What he does know is that the passengers were substantially intoxicated when they got on the plane and may have caused the accident. TSB also noted that these aircraft seats do not have latches to keep the seat backs in place, whereas in cars, for example, have latches on the seats which stop them from folding over. TSB also believes that this increases the need for pilots to wear shoulder harnesses in Cessna 185s. This is not a problem in a Beaver.

He indicated another consideration is the ability of the pilot to assess intoxicated passengers. It has been pointed out that this is well within the pilot’s authority. To refuse passengers, however in determining levels of intoxication and the degree of a problem it might cause, he indicated that there are no pilots who are sufficiently trained in this area (like police at road blocks) that can make a sensible judgment on intoxication. He did say that there should be more rigorous review of this by the pilots before flying this type of passengers.

Safety Management

The attitude of the TSB is that you can make good decisions if you know what will happen. The problem is an ability to make good decisions without knowing the results the risks. One of the problems in trying to invoke more effective safety management systems is that there does not appear to be any competitive advantage for carriers to do so. Humans tend to operate on the basis of "watch what happens." He also indicated that operators have to ask themselves the question for their own safety management system "can you live with your knowledge and can everyone else live without it?"

Investigations Policy – Openess

The policy of the Board is to have their investigations involve everyone concerned, which includes pilot, passenger representatives, manufacturers, carriers, etc. He said that by doing so there are really no secrets and he indicates that the TSB’s policy is that safety should not be a secret.

He also indicated that there may be some technologies out there now such as GPS based virtual images which could assist the pilot to locate horizons, etc. and have a better idea of where the aircraft is in relation to the ground. These systems are being developed and may be available now.

After answering some more questions Ken Burnett thanked Mr. Yearwood for an interesting presentation and the meeting adjourned.

Duration of meeting was 1.5 hours.


Speaker's Notes