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Halifax report coming May 18,2017

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News conference? What are they selling?

 

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Really... just publish the report.

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6 hours ago, DEFCON said:

News conference? What are they selling?

 

Do they need to explain the over two year time line in delivering this report?

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Not asking for names/details etc but was wondering......have the two pilots been able to fly since this occurrence or are they grounded until the results of the investigation are made private to AC  management  and also to the public???

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8 hours ago, DEFCON said:

News conference? What are they selling?

 

To give the CBC an opportunity to shine light in dark corners?

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18 minutes ago, Airband said:

To give the CBC an opportunity to shine light in dark corners?

Yeah, because we trust the CBC so much!

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Posted (edited)

This investigation has been the most secretive of any major accident I can recall in my career. Usually there is a reasonable amount of factual information released as the investigation progresses. It makes me wonder which rabbit hole they're going down.

Edited by J.O.

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44 minutes ago, J.O. said:

This investigation has been the most secretive of any major accident I can recall in my career. Usually there is a reasonable amount of factual information released as the investigation progresses. It makes me wonder which rabbit hole they're going down.

with any luck, one that is factual.  :tu:

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From the report:

.0 Findings

3.1 Findings as to causes and contributing factors

  1. Air Canada's standard operating procedure (SOP) and practice when flying in flight path angle guidance mode was that, once the aircraft was past the final approach fix, the flight crews were not required to monitor the aircraft's altitude and distance from the threshold or to make any adjustments to the flight path angle. This practice was not in accordance with the flight crew operating manuals of Air Canada or Airbus.
  2. As per Air Canada's practice, once the flight path angle was selected and the aircraft began to descend, the flight crew did not monitor the altitude and distance from the threshold, nor did they make any adjustments to the flight path angle.
  3. The flight crew did not notice that the aircraft had drifted below and diverged from the planned vertical descent angle flight profile, nor were they aware that the aircraft had crossed the minimum descent altitude further back from the threshold.
  4. Considering the challenging conditions to acquire and maintain the visual cues, it is likely the flight crew delayed disconnecting the autopilot until beyond the minimum descent altitude because of their reliance on the autopilot system.
  5. The approach and runway lights were not changed from setting 4 to setting 5; therefore, these lights were not at their maximum brightness setting during the approach.
  6. The system to control the airfield lighting's preset selections for brightness setting 4 was not in accordance with the NAV CANADA Air Traffic Control Manual of Operations requirement for the omnidirectional approach lighting system to be at its brightest settings.
  7. The limited number of visual cues and the short time that they were available to the flight crew, combined with potential visual illusions and the reduced brightness of the approach and runway lights, diminished the flight crew's ability to detect that the aircraft's approach path was taking it short of the runway.
  8. The flight crew's recognition that the aircraft was too low during the approach would have been delayed because of plan continuation bias.
  9. The aircraft struck terrain approximately 740 feet short of the runway threshold, bounced twice, and then slid along the runway before coming to a rest approximately 1900 feet beyond the runway threshold.
  10. At some time during the impact sequence, the captain's head struck the glare shield because there were insufficient acceleration forces to lock the shoulder harness and prevent movement of his upper body.
  11. The first officer sustained a head injury and serious injury to the right eye as a result of striking the glare shield because the automatic locking feature of the right-side shoulder-harness inertia reel was unserviceable.
  12. A flight attendant was injured by a coffee brewer that came free of its mounting base because its locking system was not correctly engaged.
  13. Because no emergency was expected, the passengers and cabin crew were not in a brace position at the time of the initial impact.
  14. Most of the injuries sustained by the passengers were consistent with not adopting a brace position.

3.2 Findings as to risk

  1. If aircraft cockpit voice recorder installations do not have an independent power supply, additional, potentially valuable information will not be available for an investigation.
  2. If Transport Canada does not consistently follow its protocol for the assessment of aeromedical risk and ongoing surveillance in applicants who suffer from obstructive sleep apnea, some of the safety benefit of medical examinations will be lost, increasing the risk that pilots will fly with a medical condition that poses a risk to safety.
  3. If new regulations on the use of child-restraint systems are not implemented, lap-held infants and young children are exposed to undue risk and are not provided with a level of safety equivalent to that for adult passengers.
  4. If passengers do not dress appropriately for safe travel, they risk being unprepared for adverse weather conditions during an emergency evacuation.
  5. If the type of approach lighting system on a runway is not factored into the minimum visibility required to carry out an approach, in conditions of reduced visibility, the lighting available risks being less than adequate for flight crews to assess the aircraft's position and decide whether or not to continue the approach to a safe landing.
  6. If they do not incorporate a means of absorbing forces along their longitudinal axis, vertically mounted, non-structural beams (channels, tubes, etc.) in cargo compartments could penetrate the cabin floor when the fuselage strikes the water or ground, increasing the risk of aircraft occupants being injured or emergency egress being impaired.
  7. If an aircraft manufacturer's maintenance instructions do not include the component manufacturer's safety-critical test criteria, the component risks not being maintained in an airworthy condition.
  8. If there is a complete loss of electrical and battery power and the passenger address system does not have an independent emergency power supply, the passenger address system will be inoperable, and the initial command to evacuate or to convey other emergency instructions may be delayed, putting the safety of passengers and crew at risk.
  9. If passengers retrieve or attempt to retrieve their carry-on baggage during an evacuation, they are putting themselves and other passengers at a greater risk of injury or death.
  10. If passengers do not pay attention to the pre-departure safety briefings or review the safety-features cards, they may be unprepared to react appropriately in an accident, increasing their risk of injury or death.
  11. If an organization's emergency response plan does not identify all available transportation resources, there is an increased risk that evacuated passengers and crew will not be moved from an accident site in a timely manner.
  12. If organizations do not practise transporting persons from an on-airport accident site, they may be insufficiently prepared to react appropriately to an actual accident, which may increase the time required to evacuate the passengers and crew.

3.3 Other findings

  1. The service director assessed the evacuation flow as good and determined that there was therefore no need to open the R1 door.
  2. The flight attendants stationed in the rear of the aircraft noted no life-threatening hazards. Because no evacuation order had been given, and deplaned passengers and firefighters were observed walking near the rear of the aircraft in an area where the deployment of the rear slides may have created additional hazards or risks, the flight attendants determined that there was no requirement to open the L2 and R2 doors.
  3. Although Transport Canada required the dual-exit drill to be implemented in training, it did not require all cabin crew to receive the training before an organization implemented the 1:50 ratio.
  4. At the time of the accident, neither the service director nor the flight attendants had received the dual-exit training, nor were they aware of the requirement for such training in order for Air Canada to operate with the exemption allowing 1 flight attendant for each unit of 50 passengers.
  5. Although Transport Canada had reviewed and approved Air Canada's aircraft operating manual and the standard operating procedures (SOPs), it had not identified the discrepancy between the Air Canada SOPs and the Airbus flight crew operating manual regarding the requirement to monitor the aircraft's vertical flight path beyond the final approach fix when the flight path angle guidance mode is engaged.
  6. A discrepancy in the Halifax International Airport Authority's standby generators' control circuitry caused the 2 standby generators to stop producing power.
  7. Air Canada's emergency response plan for Halifax/Stanfield International Airport indicated that the airline was responsible for the transportation of passengers from an accident site.
  8. Air Canada's emergency response plan did not identify the airport's Park'N Fly mini-buses as transportation resources.
  9. The Halifax International Airport Authority's emergency response plan did not identify that the airport Park'N Fly mini-buses could be used to transport the uninjured passengers, nor did it provide instructions on when and how to request and dispatch any transportation resources available at the airport.
  10. The Air Canada Flight Operations Manual did not identify that the required visual reference should enable the pilot to assess aircraft position and rate of change of position in order to continue the approach to a landing.
  11. In Canada, the minimum visibility that is authorized by the operations specification for non-precision approaches does not take into account the type of approach lighting system installed on the runway.
  12. It is likely that, during the emergency, a passenger activated the L1 door gust lock release pushbutton while trying to expedite his or her exit, which allowed the door to move freely.
  13. The passenger seatbacks were dislodged because the shear pins had sheared, likely as a result of contact with passengers during the impact sequence or emergency egress.
  14. Recovery of the uninjured passengers from the accident site was delayed owing to a number of factors, including the severe weather conditions; the failure of the airport's 2 standby generators to provide backup power after the loss of utility power; the loss of the airport operations radio network; and the lack of arrangements for the dispatch of transportation vehicles until after emergency response services had advised that all passengers were evacuated and the site was all clear.
  15. Given that the captain rarely used continuous positive airway pressure therapy, he would have been at risk of experiencing fatigue related to chronic sleep disruption caused by obstructive sleep apnea. However, there was no indication that fatigue played a causal or contributory role in this occurrence.

4.0 Safety action

4.1 Safety action taken

4.1.1 Air Canada

Air Canada has issued the following documentation:

  1. Flight Operations Manual (FOM) Bulletin 324, which amends the FOM Approach Policy in a number of areas, including the following changes:
    • The Required Visual Reference list now includes VASI/PAPI [visual approach slope indicator/precision approach path indicator] as an option.
    • The definition of Required Visual Reference has been amended.
    • The "lights only" call has been removed from standard operating procedures.
    • Pilot monitoring duties have been modified to require a greater emphasis on instrument monitoring during all approaches after the minimum descent altitude.
    • The Approach Visibility Requirements in Canada – 75% of Charted Visibility section for non-precision approaches has been revised to reflect the link between approved minimums and approach lighting requirements.
  2. FOM Bulletin 322: Threat-Based Briefings, which codifies and embeds the threat-based briefing format for all departure and approach briefings into the Air Canada standard operating procedures.
  3. Aircraft Technical Bulletin 482: Revised NPA [non-precision approach] Vertical Descent Approaches, to provide clarity when flying Vertically Selected Non-Precision Approaches. The bulletin contains the following warning: "FPA [flight path angle] is not a vertical navigation system. It is an angle in space. The aircraft may drift above or below the vertical profile."

Air Canada has submitted a letter to Transport Canada requesting that the standard for approach minimums be tied to the approach lighting capability of the runway, and that the corrected minimums be published on the approach plates.

Air Canada has contacted 9 airports in Canada to recommend that they upgrade their approach lighting currently serviced by omnidirectional approach lighting system (ODALS) to simplified short-approach lighting system with runway alignment indicator lights (SSALR) systems. The airline has also coordinated and participated in specific meetings with airport authorities at Halifax, Ottawa, and Kelowna to discuss its concerns, highlight operational impacts and considerations, and advocate for immediate improvements to existing ODALS.

Air Canada is working with Airbus to develop service bulletins to install global positioning systems on the 47 Airbus aircraft that are not so equipped and has started a project to upgrade the enhanced ground proximity warning system software on all Air Canada aircraft. These updates are expected to be completed by July 2017.

Flight attendant training has been amended to incorporate practical training on 2-door operation.

Air Canada's Express regional partner airlines have aligned their non-precision approach ban policy to adopt the changes in Air Canada FOM Bulletin 324.

4.1.2 Airbus

Airbus has revised the Aircraft Maintenance Manual to reflect the seat manufacturer's component maintenance manual update, which recommends that the shoulder-harness webbing be extended 25% before testing the operation of the inertial reel.

4.1.3 Halifax International Airport Authority

In response to requests and information Halifax International Airport Authority (HIAA) received from Air Canada following this occurrence, the HIAA has installed high-intensity approach lighting systems on Runway 05 and Runway 32. The existing ODALSs on both runways were replaced with SSALR systems. Transport Canada and NAV CANADA were consulted throughout the planning, design, and construction phases.

The HIAA has equipped its emergency operations centre with updated equipment such as laptop computers, mobile radios, and wireless access points.

A backup emergency operations centre has been established.

An automated mass notification system, which is used to call back personnel during emergencies, has been installed.

The emergency response plan has been revised to include a list of on-site assets available for use during emergencies.

The emergency response vehicles have been fitted with rescue sheets, which are thermal blankets for survival emergencies.

The frequency of testing of the personal communication system has been increased.

An intelligent uninterrupted power supply, which monitors and identifies faults and usage, has been installed for the network switch.

The utility service to the airport's main electrical substation has been upgraded to provide automatic switching between 2 distinct utility feeds, supplied from 2 independent Nova Scotia Power substations.

The standby diesel generator power system has been upgraded. The existing system was replaced with a new system using 3 generators. The new arrangement provides redundant capacity so that the standby system will be able to supply the full electrical load of the airport with only 2 of the 3 generators operating.

4.1.4 NAV CANADA

NAV CANADA issued a directive (effective 15 January 2016) to air traffic control personnel regarding the anomaly in the lighting panel preset buttons. The directive included instructions to refer to their Manual of Operations for lighting settings.

In August 2015, NAV CANADA published lateral navigation, vertical navigation, and localizer performance with vertical guidance approaches at Halifax/Stanfield International Airport on the area navigation (global navigation satellite system) Z Runway 05 approach plate.

This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 15 February 2017. It was officially released on 18 May 2017.

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4. Considering the challenging conditions to acquire and maintain the visual cues, it is likely the flight crew delayed disconnecting the autopilot until beyond the minimum descent altitude because of their reliance on the autopilot system.

Likely? With the flight crew surviving this incident wouldn't the TSB have asked this question. 

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The TSB explained that this accident happened due to a confluence of events. Remove one variable, and it is likely the accident would not have occurred.

Once again, it would appear that the opportunity was missed to require that Canada harmonize to the ICAO approach ban standard for non-precision approaches - charted visibility only.

Also missing seems to be the affect that GPS/EGPWS may have had on providing earlier information or warning to the crew of proximity to terrain short of the runway.

The report seems to indicate that AC has been internally proactive in both regards since the accident.

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47 minutes ago, rudder said:

The TSB explained that this accident happened due to a confluence of events. Remove one variable, and it is likely the accident would not have occurred.

Wow. Someone write this down and pass it on.  

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Posted (edited)

26 minutes ago, blues deville said:

Wow. Someone write this down and pass it on.  

 It was a quote from the investigators. Next time for your benefit I will add " ".

Edited by rudder

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43 minutes ago, rudder said:

 It was a quote from the investigators. Next time for your benefit I will add " ".

Hey rudder. All good and fully understood it was a quote from the TSB. Their comment struck me as funny in that it's a pretty well known factor in any accident or incident. Perhaps the only way  they could explain this odd one to the public. 

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No problem. The "holes in the cheese" analogy is one of the most common references in the wake of an accident but the real focus should be on how the cheese got there in the first place.

Approach ban visibility rules in Canada are inconsistent with global standards. Not seeing that fact identified in the report and no recommendation for regulatory harmonization from the TSB seems to be a glaring oversight after 2 years of investigation. With the reported visibility there was zero chance of the crew having reliable vertical approach path verification information at MDA given the equipment on board and the positioning of the PAPI array on runway 05. If you are going to fly an SCDA profile then there must be such reference available at the MDA. That would have required the published visibility for the LOC 05 approach or the equipment to perform the RNAV 05 to LPV minimums (250' AGL).

AC seems to have acknowledged these issues and has made internal changes to approach ban limitations and is asking the regulator to examine implementing those same changes.

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So have Nav Canada and YHZ got together and installed a functioning glide slope yet ???

I am sure the waterfall or giant lobster display has had a make over by now.

A very small first step was changing and an improvement to the approach lighting for runway 05 and 32.

Haven't read the report yet, but was the PAPI working that evening ???

 

 

 

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Posted (edited)

1 hour ago, AIP said:

 

Haven't read the report yet, but was the PAPI working that evening ???

From the TC report...

At the time of the occurrence, the PAPI was on setting 4 and had been on this setting since the morning of the previous day.

Edited by Kip Powick

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1 hour ago, AIP said:

So have Nav Canada and YHZ got together and installed a functioning glide slope yet ???

You funny man!  No G/S but the shopping mall is coming along nicely.

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Have read the completed report...much too long and certainly full of information that is not relevant to the accident....unless TC is going to send copies to everyone who flies with any airline in any aircraft type.

What is the point of lecturing readers on what to wear and how to "brace".??.......no wonder the report took so long....everyone wanted to get an "oar" in.<_<

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The lack of approach ban harmonization and navaid modernization should have been bullet points 1 and 2. 

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"The "holes in the cheese" analogy is one of the most common references in the wake of an accident but the real focus should be on how the cheese got there in the first place."

I admit to being out of the loop for awhile now, but I've never heard that analogy?

In my experience the pathway to the crash was described as a chain and its links referred to as 'causal factors'. Frequently, the final insult to safe flight is something that ties the causal factors together and ends in a crash, it is the 'master link'.

 

 

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Posted (edited)

 

"1.5.1.2 First officer

The FO had 15 years of experience at Air Canada and had flown as an FO on the A320 since being hired."

This factoid strikes me as odd and raises a couple of questions the report doesn't address?

 

 

Edited by DEFCON

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