Reasessment of the response to TSB recommendation A20-01
Landing minima in Canada
On 26 February 2018, a Beechcraft King Air A100 (registration C-GJXF, serial number B‑159) operated by Strait Air (2000) Ltd. was conducting charter flight NUK107 under instrument flight rules, from the Sept-Îles Airport, Quebec, to the Havre St-Pierre Airport, Quebec, with 2 crew members and 6 passengers on board. The aircraft conducted an approach to Runway 08, which was snow-covered, while visibility was reduced due to heavy snow showers, and landed approximately 3800 feet beyond the threshold, at approximately 700 feet from the end of the runway. It continued its landing roll beyond the runway until it came to rest in a snowbank, approximately 220 feet beyond the end of the runway. The accident occurred in daylight, at 1120 Eastern Standard Time. The emergency locator transmitter, transmitting on 406 MHz, did not activate following the occurrence. The aircraft sustained substantial damage. Four of the occupants received minor injuries.
The Board concluded its investigation and released report A18Q0030 on 21 May 2020.
TSB Recommendation A20-01 (May 2020)
In designing instrument approaches, the published minimum visibility represents the minimum visibility at which a pilot on approach at the decision height (DH) or the minimum descent altitude (MDA) should be able to establish and maintain the visual reference required up until landing.
International Civil Aviation Organization (ICAO)Footnote 1 standards and recommended practices stipulate that an instrument approach shall not be continued unless the reported visibility is at or above the specified minima. These minima are published on approach charts based on the approach type and lighting.
Various civil aviation authorities throughout the world (such as the U.S. Federal Aviation Administration (FAA) and the European Union Aviation Safety Agency (EASA)) have established that the authorized visibility minima are those specified and published for the approach. Therefore, to determine whether an approach is authorized, it is simply a matter of comparing the reported visibility with the visibility published on the approach chart. Consequently, air traffic control (ATC) will not clear an aircraft for approach if the reported visibility is less than what is published on the approach chart.
In Canada, visibilities published on approach charts are provided for information purposes only.
To determine whether an aircraft can legally land at an aerodrome in Canada, consideration must first be given to the operational restrictions that apply to the aerodrome in question to ensure that the aerodrome is suitable for the manoeuvre being executed.Footnote 2 One of the determining factors is the aerodrome’s operating visibility, which is defined in the Canada Air Pilot (CAP 5) in the general pages pertaining to operating minima.Footnote 3 This operating visibility limit is published in the Canada Flight Supplement (CFS), specifically in the box reserved for runway information. If an aerodrome’s operating visibility limit is not published in the CFS, it means that operations are not authorized when visibility is less than ½ statute mile (SM).
Next, the minimum visibility for an approach ban must be calculated to determine whether the approach can continue to the DH or the MDA. This minimum visibility is calculated based on the visibility published on the approach chart, and varies depending on the type of operations:
- ¾ of the published visibility for commercial operators;
- ½ of the published visibility for commercial operators who have Operations Specification 019 regarding reduced visibility;
- ¼ SM for private operators, regardless of the approach being conducted.
According to this calculation, the minimum visibility for an approach ban in Canada is less than the visibility published on the approach chart in every case. Consequently, it is likely that, once at the DH or MDA, pilots are not able to establish the required visual reference that will help them make a safe landing.
Between December 2006Footnote 4 and December 2019, 31 incidents occurred following approaches conducted below the MDA with few visual references. Of these 31 incidents, 17 occurred during a landing in weather conditions where visibility was below what is published on the approach chart.Footnote 5 Furthermore, this situation continues to occur today: 9 of the 17 incidents have occurred within the past 5 years.
In Canada, due to the complexity and variations in minima based on the type of operations, it is difficult for ATC to determine whether the planned approach is banned. It will clear an aircraft for approach regardless of the published minima, contrary to what is done elsewhere in the world. Therefore, it is up to the captain to interpret the approach ban, and it is the captain who decides whether or not to continue with the approach.
In this occurrence, based on his interpretation of numerous conditions and exceptions relating to the approach ban, the captain incorrectly believed that he was allowed to conduct the approach. The first officer was aware that weather conditions were below the approach minima published in the CAP, but he did not understand all of the details involved in the approach ban. He was therefore unable to challenge the captain’s decision to conduct the approach, and the captain continued the approach beyond the final approach fix when the reported visibility was below the approach ban minima. The captain then proceeded with the landing sequence without seeing or knowing the length of the remaining runway ahead and unable to accurately assess the aircraft’s position.
Given that it was difficult for the flight advisory service and the aerodrome operator to determine whether the approach was banned, they could not inform the pilots that the approach was banned under the existing conditions, despite the fact that visibility was one quarter of what was published on the approach chart.
Therefore, if Transport Canada (TC) does not simplify approach and landing operating minima, flight crews may proceed with an approach that is actually banned, thereby increasing the risk of approach-and-landing accidents, including runway overruns.
Consequently, the Board recommended that
the Department of Transport review and simplify operating minima for approaches and landings at Canadian aerodromes.
TSB Recommendation A20-01
Transport Canada’s response to Recommendation A20-01 (August 2020)
The two recommendations are related and will be addressed in a single response.
TC agrees with Recommendation A20-01 and, as outlined below, has already initiated work to implement improvements to the regulations governing approaches and landings at Canadian aerodromes.
TC also agrees with Recommendation A20-02. While recognizing that it may be difficult to stop all approaches and landings that are prohibited through the regulations, introducing simpler regulations in keeping with Recommendation A20-01 will make them easier to follow and to enforce. Furthermore, TC will investigate possible improvements to education and enforcement as part of its upcoming work in this area.
The safety issues raised by the two recommendations are not unknown to TC. The complexity of the current approach ban regulations, promulgated in 2006, are the result of multiple compromises following consultations with industry to reflect the diverse realities facing Air Operators. As such, TC has already carried out significant work on this issue in the past five years:
- In 2015, TC developed an issue paper that was presented to the National Civil Aviation Management Executive Committee (NCAMX) recommending that the regulations should be revised to harmonize with international standards, and to update standards for calculating approach visibility.
- In November 2017, TC developed, and circulated through the Canadian Aviation Regulation Advisory Council (CARAC), a Preliminary Issue and Consultation Assessment (PICA) to establish a better understanding of industry concerns and to assist with regulatory development.
- In January 2018, the Assessment concluded that there was a need for consultation with all stakeholders through focus groups and to support to [sic] the harmonization with international standards and best practices.
Due to the complexity of the issue, stakeholders raised specific concerns related to the workload associated with implementation; potential service impacts in the North if changes to the approach ban are not done alongside infrastructure improvements; applicability of the changes to the approach ban to helicopter operations; and the need to harmonize proposed changes to the approach ban with changes to lighting standards.
Due to other competing priorities, this was the most recent work carried out by TC on this issue.
TC recognizes that more work needs to be done to mitigate the risks. To this end, revisions to the approach ban regulations (A20-01) must precede steps to ensure the new regulations are followed (A20-02). Building on the aforementioned work and comments received from stakeholders, TC is forming, and will lead, an industry working group on this issue. The working group will have the mandate to deliver on the following:
- Update to TP308/GPH209 - Criteria for the Development of Instrument ProceduresFootnote 6 to support new regulations with approach visibility calculations that account for runway approach lighting systems;
- Notice of Proposed Amendment (NPA) to update approach ban regulations as well as the supporting documentation and guidance; and,
- Review of potential measures to encourage and enforce compliance with updated approach ban regulations considering all tools in the regulatory toolbox and the experience of other jurisdictions.
In order to produce the deliverables above, the work will be divided into two phases:
- The first phase will involve a Policy review of the situation and will culminate with a Policy Discussion Paper and a Focus Group(s) with industry.
- During the second phase, the working group will begin the regulatory development that includes an NPA to be completed by January 2021 and have the draft instructions and the pre-publication of the new regulation in Canada Gazette Part I by the end of 2021. The final publication in Canada Gazette Part II will be approximately one year after Part I.
TSB assessment of Transport Canada’s response to Recommendation A20-01 (November 2020)
In its response, Transport Canada (TC) indicated that it agrees with Recommendation A20-01 and has already initiated work to implement improvements to the regulations governing approaches and landings at Canadian aerodromes.
TC also recognizes that more work needs to be done to mitigate the risks associated with the safety deficiency identified in Recommendation A20-01, and will lead an industry working group that will draft a Notice of Proposed Amendment to update approach ban regulations, as well as the supporting documentation and guidance. TC expects to publish the proposed regulations in the Canada Gazette, Part I, by the end of 2021.
The Board is encouraged by TC’s planned actions to address the safety issues associated with the complexity of the landing minima in Canada. These actions, when fully implemented, have the potential to substantially mitigate the risks associated with the safety deficiency identified in Recommendation A20-01.
Therefore, the Board considers the response to Recommendation A20-01 to show Satisfactory Intent.
Next TSB action
The TSB will monitor the progress of TC's planned actions to mitigate the risks associated with the safety deficiency identified in Recommendation A20-01, and will reassess the deficiency on an annual basis or when otherwise warranted.
This deficiency file is Active.
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