AVIATION Reports - 1997 - A97H0011

Table of Contents

1. 1.0 Factual Information
   1. 1.1 History of the Flight
   2. 1.2 Injuries to Persons
   3. 1.3 Damage to Aircraft
   4. 1.4 Other Damage
   5. 1.5 Personnel Information
   6. 1.5.1 General
   7. 1.5.2 Captain
   8. 1.5.3 First Officer
   9. 1.5.4 Cabin Crew
   10. 1.6 Aircraft Information
   11. 1.6.1 General
   12. 1.6.2 Aircraft Systems
   13. 1.6.2.1 Flight Director
   14. 1.6.2.2 Stall Protection System
   15. 1.6.2.3 Airspeed Indications
   16. 1.6.2.4 Flaps
   17. 1.7 Meteorological Information
   18. 1.7.1 General
   19. 1.7.2 Forecast Weather
   20. 1.7.3 Actual Weather
   21. 1.7.4 Icing Conditions
   22. 1.8 Aids to Navigation
   23. 1.9 Communications
   24. 1.10 Aerodrome Information
   25. 1.10.1 General
   26. 1.10.2 Runway Lighting and Runway Visual Range
   27. 1.10.3 Runway Condition
   28. 1.10.4 Air Traffic Services
   29. 1.11 Flight Recorders
   30. 1.11.1 General
   31. 1.11.2 Flight Data Recorder
   32. 1.11.3 Cockpit Voice Recorder
   33. 1.11.4 Flight Reconstruction
   34. 1.12 Wreckage and Impact Information
   35. 1.13 Medical Information
   36. 1.14 Fire
   37. 1.15 Survival Aspects
   38. 1.15.1 General
   39. 1.15.2 The Aircraft
   40. 1.15.3 Air Canada Emergency Procedures
   41. 1.15.4 Training - Emergency Equipment and Procedures
   42. 1.15.5 Occurrence Flight
   43. 1.15.6 Emergency Response
   44. 1.15.7 Emergency Locator Transmitter
   45. 1.16 Tests and Research
   46. 1.17 Organizational and Management Information
   47. 1.17.1 Air Canada Regional Jet Training Program
   48. 1.17.1.1 Introduction
   49. 1.17.1.2 Pilot Training
   50. 1.17.1.3 Line Indoctrination and Command Training
   51. 1.17.2 Crew Pairing
   52. 1.18 Other Information
   53. 1.18.1 Conduct of the Flight
   54. 1.18.1.1 General
   55. 1.18.1.2 Assignment of Flying Duties
   56. 1.18.1.3 Final Approach to Go-around Command
   57. 1.18.1.4 The Go-around
   58. 1.18.1.5 Stall Prevention
   59. 1.18.1.6 Runway Length
   60. 1.18.2 Approach and Landing Issues
   61. 1.18.2.1 Category I and Category II Approaches
   62. 1.18.2.2 Approach Bans
   63. 1.18.2.3 Approach Criteria
   64. 1.18.2.4 Loss of Visual References after Deciding to Land
   65. 1.18.2.5 Approach Procedures
   66. 1.18.2.6 Weather-related Occurrences
   67. 1.18.3 Aircraft Performance
   68. 1.18.3.1 General
   69. 1.18.3.2 Stall Protection System Activation
   70. 1.18.3.3 Coefficient of Lift Curve
   71. 1.18.3.4 Flight Data Recorder Data from Previous Flight
   72. 1.18.3.5 Flight Data Recorder Data from Aircraft 104
   73. 1.18.3.6 Simulator Comparison
   74. 1.18.3.7 Wing Condition
   75. 1.18.3.8 Ground Effect
   76. 1.18.3.9 Ice Accretion
   77. 1.18.3.10 Ice Detection and Protection
2. 2.0 Analysis
   1. 2.1 Introduction
   2. 2.2 Survival Aspects
   3. 2.2.1 Training on Evacuation and Emergency Equipment
   4. 2.2.2 Survival Equipment - Signalling Tools
   5. 2.2.3 Emergency Equipment - Location of Flashlights
   6. 2.2.4 Passenger Preparedness for Post-Evacuation Survival
   7. 2.2.5 Emergency Response
   8. 2.3 Operational Issues
   9. 2.3.1 Approach and Transition to Land
   10. 2.3.1.1 Approach Ban Weather Limits
   11. 2.3.1.2 Weather Conditions and Effects on this Flight
   12. 2.3.1.3 Low-Weather Procedures
   13. 2.3.2 Assigning First Officer Pilot-Flying Duties
   14. 2.3.3 Captain Duties on Approach
   15. 2.3.4 Go-around Issues
   16. 2.3.4.1 Low-Energy Rejected Landing Considerations
   17. 2.3.4.2 Flight Director Guidance
   18. 2.3.4.3 Go-around Procedure and Training
   19. 2.3.5 Flight Monitoring
   20. 2.3.6 Stall Recovery Procedures
   21. 2.3.7 Wing Anti-Ice Procedures
   22. 2.3.8 Runway Length
   23. 2.4 Wing Performance Issues
   24. 2.4.1 Introduction
   25. 2.4.2 Analysis of C_L-Alpha Curves
   26. 2.4.3 Analysis of Simulator Results
   27. 2.4.4 Factors Affecting Performance Loss
   28. 2.4.4.1 Wing Condition
   29. 2.4.4.2 Ground Effect
   30. 2.4.4.3 Ice Accretion
   31. 2.4.4.4 Flap Movement
   32. 2.4.4.5 Interactions of Lift-degrading Factors
   33. 2.4.4.6 Performance Loss Summary
   34. 2.4.5 Stall Protection System - Certification and Functioning
3. 3.0 Conclusions
   1. 3.1 Findings as to Causes and Contributing Factors
   2. 3.2 Other Findings
4. 4.0 Safety Action
   1. 4.1 Action Taken
   2. 4.1.1 Use of Aircraft Anti-Ice
   3. 4.1.2 Requirement for an Emergency Locator Transmitter
   4. 4.1.3 Aircraft Low-Energy Issues
   5. 4.1.4 Procedures and Training
   6. 4.1.5 CL-65 Wing Maintenance
   7. 4.1.6 Safety Information Letters
   8. 4.1.7 Practical Training
   9. 4.2 Action Required
   10. 4.2.1 Low-Weather Approaches
   11. 4.2.2 Low-Energy Go-arounds
5. 5.0 Appendices
   1. Appendix A - Fredericton Approach Plate for ILS-15
   2. Appendix B1 - Aircraft Wreckage Plot
   3. Appendix B2 - Wreckage Plot Code
   4. Appendix C - Computed Versus Expected C_L-Alpha Curve
   5. Appendix D - List of Supporting Reports
   6. Appendix E - Glossary
6. List of Figures
   1. Figure 1 - Aircraft Interior
   2. Figure 2 - Two-engine Go-around
   3. Figure 3 - Approach and Runway Lighting

Previous | Next