Tim Hortons co-founder reported to be OK after plane crashes

[ez4u2say]

Check it out..from AVwebBiz today

As the FAA gets ready to implement mandatory safety management systems (SMSs), Canadian authorities are warning SMSs need proper oversight if they're to do their job of improving flight safety. The Canadian Transportation Safety Board cited insufficient oversight of a private operator's SMS in its final report on a landing accident that injured 10 people aboard a Bombardier Global 5000 at Fox Harbour, N.S., two years ago. Transport Canada has required SMS plans for commercial carriers for years but delegated oversight of SMS implementation for some operators to the Canadian Business Aviation Association in 2003. The TSB said in its report that CBAA's implementation of SMS criteria is flawed and Transport Canada failed to recognize that before the Nova Scotia accident. "This is a serious problem," said Kathy Fox, board member for the TSB. "Safety can be compromised when SMS plans are vague, deadlines are flexible, and critical oversight is lacking. Without proper milestones or auditing, SMS cannot function properly and the risks increase." The flawed SMS process is a thread throughout the TSB's findings, which determined the pilots ducked under the standard approach and, because they were used to flying smaller aircraft into the field, misjudged the touchdown and hit the ground seven feet before the pavement. More...

[Widow]

Heard from a good source the both pilots were dismissed by Ron J.

Seriously?

No doubt the CBAA is regretting the day they let TC con them into taking over certification responsibility for private operators.

Another identified concern was the potential liability of the self-regulating body and its board of directors. By producing its own standards and certifying operators to those standards, it was reasoned that the CBAA would assume a responsibility that implied a certain duty of care. This duty of care, it followed, would bring with it potential liability for negligence if a certificate holder had an accident that was reasonably foreseeable or an accredited auditor was found negligent.

[xsbank]

We just went through a series of meetings to explain the SMS system where I work. It seems to be a great system when reporting mechanical things that may be a hazard but the so-called "non-punitive" reporting system is the weak link; the reason it will never be truly successful or reach the level of success its proponents hope for, until there is a true level of protection for the workers - whistle-blower protection. Unless this happens, the human-factors part of SMS will never be successful because those involved in an issue will bury it in silence for fear of being sanctioned.

Whistle-blower protection, like Widow has tried to rally us to support. Essential, the foundation of the whole process, or its just lip-service like TQM or Six Sigma or whatever the latest business buzzword.

[Rubberbiscuit]

Heard from a good source the both pilots were dismissed by Ron J.

Seriously?

That is usually the outcome when pilots wreck a perfectly good airplane. I am not suggesting it couldn't have happened to anybody, but the pilots made an error as a result of not being familiar with the limitations of the approach light guidance system. I am trying to wrap my head around how this would not have happened if SMS was fully implemented by the CBAA, or never existed in the first place?

[pelmet]

[quote="Rubberbiscuit"] I am trying to wrap my head around how this would not have happened if SMS was fully implemented by the CBAA, or never existed in the first [/list]place?[/quote]

Exactly. Why don't they just get rid of this CBAA money/time wasting crap and do like they do in the U.S. when you get a turboprop or jet. It operates under private rules. The best thing they can do is make it mandatory to read lots of accident reports.

[learcapt]

Both pilots were not fired..I know that one still has his job.

[Widow]

But WHY weren't the pilots familiar with the approach light guidance system? I think the point the TSB report is making is that this is exactly the sort of "risk" that an SMS is supposed to identify BEFORE it causes an incident/accident. Look at all the holes in the swiss cheese model. The pilots did not wreck the aircraft on purpose. It would appear they wrecked it because they weren't trained properly, because the added risk wasn't identified and the overseers, and overseers of the overseers, did not ensure added risks had been identified and addressed.

And hey, SMS is supposed to be non-punitive. No pilot should lose a job for having an accident as a result of inadequate training - the responsibility of the risk assessor!

[Big Pistons Forever]

But WHY weren't the pilots familiar with the approach light guidance system? I think the point the TSB report is making is that this is exactly the sort of "risk" that an SMS is supposed to identify BEFORE it causes an incident/accident. Look at all the holes in the swiss cheese model. The pilots did not wreck the aircraft on purpose. It would appear they wrecked it because they weren't trained properly, because the added risk wasn't identified and the overseers, and overseers of the overseers, did not ensure added risks had been identified and addressed.

And hey, SMS is supposed to be non-punitive. No pilot should lose a job for having an accident as a result of inadequate training - the responsibility of the risk assessor!

The ultimate risk assesor has to always be the PIC. That being said the primary cause of this accident was a failure to appreciate the eye to wheel hight, the significance of which, was missed by TC, Bombardier, The training establishments, and finally by the pilots. The first thing that struck me when I read about this accident was the fact they were flying such a big airplane into such a little strip. This is an accident analysis classic. Irving has flown into this strip for many years but started with relatively light aircraft and then moved on to increasing bigger aircraft with what appears to be no systematic and comprehensive analysis on what effect a change to the type of aircraft would have on the risk operating into this airport. THAT is what safety management is supposed to be about, and with the way CBAA runs their audits will always be the excepton rather than the rule.

[pelmet]

[quote="Widow"]But WHY weren't the pilots familiar with the approach light guidance system? I think the point the TSB report is making is that this is exactly the sort of "risk" that an SMS is supposed to identify BEFORE it causes an incident/accident. Look at all the holes in the swiss cheese model. The pilots did not wreck the aircraft on purpose. It would appear they wrecked it because they weren't trained properly, because the added risk wasn't identified and the overseers, and overseers of the overseers, did not ensure added risks had been identified and addressed.
[/quote]

If you think SMS is all about telling pilots that their aircraft's eye-to-wheel height is too big for the PAPIS on a particular runway, or that trying to touch down right at the vey beginning can be risky if there is a lip at the beginning of the runway then you are way off. There are a million gotchas out there, some aircraft specific, some not. I have read of plenty of aircraft over the years touching down short and damaging gear, from a light aircraft to a 727.

I have been checked out in probably 30 aircraft in my life and nobody ever mentioned about eye to wheel heights. Was their training improper because the trainers didn't mention every little hazard out there? They must have had a sim instructor as a trainer. Why do you feel that he is to blame. Or was it their ground school instructor who failed. I think not. I think it is a cop out to blame the trainers and overseers, etc for not mentioning every potential hazard out there.

Bottom line: I and plenty of other pilots knew about this. Maybe these pilots knew as well and forgot. Maybe I would have as well in the heat of the action. Thinking that somehow, some sort of SMS program would have changed the outcome is naive. You have to figure out a lot of stuff on your own. The best way is by reading.

But in this country, we have add more regulation when something like this happens. These aircraft should operate without having this CBAA stuff. Make it like the U.S. There you can takeoff and initiate an approach in Zero/zero conditions.

[Big Pistons Forever]

Denial...the first obstacle to change....

[pelmet]

[quote="Big Pistons Forever"]Denial...the first obstacle to change....[/quote]

O.K. then, I was wrong. They were not trained properly as Widow says. We should obviously blame the sim and ground school instructors. Perhaps termination of their employment is appropriate. Only more restrictive rules will prevent it in the future no doubt.

Maybe someone could tell me why you need to have an ops manual and this CBAA stuff to operate a turbine aircraft in Canada when you don't(as far as I know) in the U.S. Perhaps the mindset that only more and more regulation will somehow solve our problems no matter what the expense.

You can't regulate common sense(like being foolish enough to push a popped fuel flow CB back in during flight because the weather is nice) or a multitude of other things. But you can try to disseminate as much accident and incident information as possible to let people learn from the mistakes of others. Such as why you can wait til you land to push a CB in or knowledge about PAPIS/VASIS. There are better ways to improve safety than a thick CBAA manual. I've started to read one where I fly on my time off. Lots of pages of stuff. No doubt it cost a bunch.

[Rubberbiscuit]

But WHY weren't the pilots familiar with the approach light guidance system? I think the point the TSB report is making is that this is exactly the sort of "risk" that an SMS is supposed to identify BEFORE it causes an incident/accident. Look at all the holes in the swiss cheese model. The pilots did not wreck the aircraft on purpose. It would appear they wrecked it because they weren't trained properly, because the added risk wasn't identified and the overseers, and overseers of the overseers, did not ensure added risks had been identified and addressed.

And hey, SMS is supposed to be non-punitive. No pilot should lose a job for having an accident as a result of inadequate training - the responsibility of the risk assessor!

The report states that SMS may have identified several deficiencies with the operation. The APAPI was only one of the slices in the swiss cheese model. If SMS had been implemented fully, properly and followed it could have been pilots, Jetport or Fox harbour Airport management that might have discovered the fact that the installed APAPI could become a problem if larger aircraft were to operate into the airport. Someone might have used foresight to determine that the crew, although experienced but new to the type had no business being there that particular day.

As far as non-punitive goes, it only applies if nobody was being recless or negligent. These pilots was well BELOW the approach slope provided by the APAPIs. If they had flown the APAPIS all the way down they would have touched down safely with a reduced clearance height at the threshold. The pilots ended up low and slow. When they crossed the threshold they were 16 knots below target speed with an excessive nose up attitude of 10.6 degrees to be exact). ACcording to the TSB report, nothing was done at any point to try and correct this situation.

[_dwj_]

I have to agree with pelmet. I don't see how SMS or CBAA could have done much to prevent this accident. The best thing would be for pilots to read more accident reports because these same factors appear all the time. A month or two ago the ASF editorial in AOPA pilot was devoted to the topic of choosing an appropriate safety margin for runway length. The more of this stuff you read, the more it sticks in your mind and you think twice before making dumb decisions. TC does a good job in sending the Aviation Safety Letter to all pilots, but unfortunately you can't make them read it!

If I was in charge of interviewing pilots the first thing I would ask them would be to describe some accident reports and the lessons learned from them.

[Donald]

The APAPI was only one of the slices in the swiss cheese model.

Plus there is the green-on-green crew (F/O hadn't flown the a/c since training 3 months prior)

The approach guidance system was not being maintained at Fox Harbour, so it was not accurate.

The company treated the Global the same as their Challenger in regards to SOP's, to the point of having statements and practices contrary to manufacturer recommendations.

It's never just one thing.

[Truckpilot]

Bumping this thread...

What's with this trend of pilots to "duck below the G/P"...? So they can save taxi time...? It's Fox Harbour for Pete's sake...!!! I'd be more concerned about having the recommended post landing, 3 minute at idle power, before shutting down an engine...

The appears to be a somewhat 'cavalier attitude' in Jetport, especially with their thinking that the 5000 can be flown/operated like a 604.
I've flown both and they can't...that's why it's a different type rating and not a differences course...

Just who is this so called 'accredited Auditor'? Seems like a 'friendship' between RJ/Jetport and this person...

Just wondering...

[_dwj_]

What's with this trend of pilots to "duck below the G/P"...? So they can save taxi time...?

No, it wasn't taxi time - here is the info from the report:

The crew members planned to fly the same approach profile they had flown on many occasions in the past, and touchdown in the first 500 feet of Runway 33, therefore maximizing the roll-out distance available. Even though this would require them to cross the threshold at a height lower than the manufacturer recommended 50-foot threshold crossing height (TCH), they felt that the risks associated with a lower TCH were acceptable. This would maximize the roll-out distance available, and compensate for the possibility of a wet runway

[CL30]

A year ago, as we waited for passengers I starting pulling some Aircraft Manuals and doing some homework into the items that are not really covered well at training. One being performance charts because the latest buzz at the time was North American operators being raked over the coals for not having adequately proved competence or having the correct information in hand while operating in Europe. The Falcon 900EX has two manuals plus multiple supplements for such items.

We had the 49,000 MTOW modification applied along with a higher landing weight. Out of the factory some of the fleet were only certified for lower weights. All of our charts for performance referenced the same page for limitations. The limitations reflected the lower take off and landing weights, not the higher ones we were using. I went through everything handy, couldn't find anything to support higher minimums. So have we been flying illegally? I talked to my co-worker about it and we decided to test the SMS system. We put in an alert.

My main concern was that all of our performance charts referenced a page that only reflected lower minimums so if we were to prove our weight and balance to any European authorities we would be in trouble as we always flew out of Europe at Max Gross Take Off Weight. Landing weight was never really much of an issue as our heavy take offs usually had 8 - 9 hours of flight time following them, but the take off weights could be an issue. The other thing with the documentation is there is no real clear answer handy to prove that the modification for the higher weights was complied with.

So the company sprung into action by calling another pilot in to review the manuals. I had already spent a good two hours looking for the correct material the day of our trip. After a day, a supplement was found but its still a vague situation as the AFM had no mention of this supplement and proving the aircraft had the modification is even harder to find on the road (MX logs kept at the base). Regardless the all clear was sounded. The fallout came in the form of a stern lecture from management regarding the issue and another one from the base manager mentioning to keep things like this quiet and go through him first before making any SMS action.

I felt from this experience that the SMS system is really just a way to enable regulators to walk in or audit you quickly by having documentation that can be used to say, "we've done our job, look at the results", and it also leaves flight crews open for punitive action as there is now a legal document that can prove or be warped into showing misconduct or not being a "team player". It is never audited or taken further upon review why the industry has such a high turn over rate or the motives for termination on the part of employers so a lot of the signs as to something being wrong are never really seen.

I really think we need something that combines "boots on the ground" with more inspectors that are "aviation" trained and minded with a an oversight system that looks at the entire picture, not just what people are willing to put into a report and paper. SMS is just the same old, if you work by bending the rules, you will continue to do so.

In regards to the "Fox Harbour" crash, it is my understanding through the grapevine that there were some distractions in the cockpit and the flight crew was not overly experienced on the aircraft. I wouldn't be so quick to blame them, Eye to Wheel Height of the PAPI doesn't replace the need to pick a safe touch down point and fly with that reference when you are visual.

The fact that the CBAA was deemed inadequate by the investigators raises a lot of red flags in my opinion as to the state of our industry.

[A Regulator]

Well here is a couple or reasons that probably happened and why the CBAA got into the picture, a very very very very long time ago the private industry was unregulated and there were a lot of company aircraft (jets) flying all over the place. Some got training and some did not, I can think of one Lear 23 or 24 operator in Alberta who liked to run a bit low on fuel, but anyway out east there was a big private company that flew the entire company executives to a meeting and well they crashed, not sure if some survived but the company almost went out of business and because of it there was a lot of political crap from the fallout such as who is regulating them and the answer was No one. So they started up ANO 1 No, 2 which laid out some rules, not many but some, this went on for quite a bit of time but it started to cost TC $$$$$ because the companies got bigger and better aircraft and TC put more Inspectors on them that cost $$$ in training. So back in 96 with the CARS came out they put them into 604 and more rules etc. but then someone in Ottawa saw that this training was costing a lot of $$$$ so a conversation/meetings was held and the CBAA was started and BTW it was going to cost $$$ to join and you had to. Then they promised to regulate themselves and then they had to have a SMS in place but I can probably tell you if no one has looked at it (at least from what I read in the report, not done very good) it probably does not meet the intent. Some 604 operators are fighting the CBAA and want State regs as they don't want to have a private company CBAA tell a provincial minister what to do. etc. Also performance issues are glanced over and many other items as they don't have time to do everything in 4 or 5 days as the company's complain to the contract providers to shorten things up. So don't give up on the SMS yet but still try and report stuff on a trip report and in regards to training you only get the basic training and not usually the STATE regulations that you are from. If you are able have some pilot meetings and discuss the items with your crewmembers and fly safe.

[Gino Under]

Having recently been introduced to the SMS process at our company through OUR safety officer and after some thoughts on how it's set up, I'd have to say it's not what I would like to see in place as a Safety Program. (not that it's up to me, but)
I may have a better/fairer opinion once I've had the opportunity to actually use it.

For one thing, the number of "managers" that oversee our safety program from the top down is ridiculous. The highest level a safety issue seems to reach is the VP, not the CEO. In my experience, safety issues have always been tied directly to the CEO. Our SMS org chart stops at the VP so it was a bit of a surprise.

I asked our FSO if he could go directly to the VP with an issue and he said no. He has to go to the next level in the chain. Does that make sense? Layers only serve to delay the process and as we all know, chains have links, and broken links cause accidents. The VP will probably be virtually inaccessable outside of specific times he sets aside to address safety issues. How does that work?

Maybe some of you have a clearer view of SMS than I or maybe I'm missing something here?

Gino Under

[the_professor]

Has anyone read the Flight Safety Foundation coverage of this? Not sure if it's been posted here yet. Good synopsis/analysis.

http://flightsafety.org/asw/dec09-jan10 ... p18-21.pdf