Air transportation safety recommendation A16-09

 Recommendation A16-09 in PDF [186 KB]

Assesssments of the response to Aviation Safety Recommendation A16-09

Instrument flight currency requirements

Background

On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2 pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter’s satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter (ELT). At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors.

The Board concluded its investigation and released report A13H0001 on 15 June 2016.

TSB Recommendation A16-09 (June 2016)

As seen in this occurrence, 2 pilots lacking instrument flying proficiency departed for a night visual flight rules (VFR) flight in conditions that required the use of instrument flying skills because the cultural and/or ambient lighting needed to maintain visual reference to the surface was lacking. Although both pilots had met the instrument flight currency requirements in the Canadian Aviation Regulations (CARs), once the aircraft passed the end of the runway lights necessitating transition to flight by reference to instruments, an excessive bank angle and rate of descent developed, which were not recognized by the crew at an altitude that permitted recovery.

Under the current regulations, instrument-rated pilots may go up to 12 months following their instrument ride before they are required to conduct any actual or simulated instrument flying. After 12 months, the regulations require pilots to have completed 6 hours of instrument flying, including 6 instrument approaches during the previous 6 months to maintain their instrument qualification (the 6/6/6 requirement). Many of these instrument-rated pilots do not routinely conduct instrument flight training or operations to maintain a reasonable degree of instrument flying proficiency. As a result, pilots who have had little to no instrument flying experience for 12 months may legally be called upon to carry out, and may accept, a challenging instrument flight without recent practice in the skills essential to the safe conduct of an instrument flight.

As identified in Transport Canada’s (TC) Instrument Procedures manual, instrument flight is a skill that requires “careful training, constant practice and a methodical approach.” As for any other skill, repetition is essential to prevent erosion of a pilot’s instrument flying skill. As explained above, the instrument currency requirements allow for an extended period (i.e., up to 12 months) to lapse before a pilot is required to complete any type of instrument flight. In contrast, there are a number of semi-annual currency requirements in the CARs, such as takeoffs and landings, which a pilot must complete in order to remain current for operational duty. A similar semi-annual requirement also exists for instrument flight; however, it only applies after the first 12 months following the issuing or renewal of an instrument rating. TC does not impose the 6/6/6 instrument currency requirement during the first 12 months. In the United States, the Federal Aviation Regulations (FARs) paragraph 61.57(c) specifies semi-annual instrument currency requirements that must be met before a pilot can act as pilot-in-command under instrument flight rules or in weather conditions less than the minimums prescribed for visual flight rules only.

The instrument recency requirements in the CARs do not provide adequate assurance that an instrument-rated pilot will possess an acceptable level of proficiency to ensure the safe conduct of a flight in challenging instrument meteorological conditions. As a result, pilots may conduct flights in challenging instrument meteorological or dark night conditions without the level of instrument flying proficiency required to maintain safe flight operations.

Therefore, the Board recommended that

The Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument-rated pilots, who may operate in conditions requiring instrument proficiency.

Transportation Safety Recommendation A16-09

Transport Canada’s response to Recommendation A16-09 (September 2016)

Transport Canada agrees with this recommendation.

TC plans to address this recommendation via a regulatory amendment and will engage the aviation community on the subject in summer 2017.

Transport Canada update (December 2016)

Transport Canada will be conducting an internal assessment on this issue, with input from many different areas within [the] Civil Aviation [Directorate]. A recommendation will be brought to senior management for approval and the aviation community will then be consulted through a Preliminary Issue & Consultation Assessment (PICA) form in the fall of 2017. Comments received through the PICA will be considered while drafting the Notice of Proposed Amendments (NPA).

TSB assessment of Transport Canada’s response to Recommendation A16-09 (December 2016)

The Board is pleased that TC plans to address this recommendation via a regulatory amendment. The Board is optimistic that the amendment will significantly reduce or eliminate the safety deficiency associated with this recommendation. However, until the regulatory amendment is published, it is impossible to determine whether or not the safety deficiency will be adequately addressed.

Therefore, the response to Recommendation A16-09 is assessed as Satisfactory Intent.

Transport Canada’s response to Recommendation A16-09 (October 2017)

TC agrees with the recommendation.

Due to other Ministerial priorities and commitments, such as UAV’s and Fatigue Risk Management, TC has been unable to move ahead on this file.

It is TC’s intention to commence work on this file by summer, 2018.

TSB reassessment of Transport Canada’s response to Recommendation A16-09 (March 2018)

In 2016, TC stated that it would address the safety deficiency identified in Recommendation A16-09 by introducing new instrument currency requirements in the Canadian Aviation Regulations (CARs). To do so, TC has made the following undertakings:

  • TC stated it would conduct an internal assessment in response to
    Recommendation A16-09, before making its own recommendations to senior TC management;
  • TC stated it would consult the civil aviation industry by means of a Preliminary Issue and Consultation Assessment (PICA) to discuss new instrument currency requirements; and
  • Upon assessing the comments received through the PICA, TC plans to draft a Notice of Proposed Amendment to update existing instrument currency requirements.

However, due to other priorities and commitments, TC did not initiate its work for any of these undertakings. 

Until TC’s planned internal assessment reaches conclusions as to how it can establish new instrument currency requirements that satisfy Recommendation A16-09, and TC provides the TSB with its plan of action moving forward following those conclusions, it is unclear when or how the safety deficiency identified in Recommendation A16-09 will be addressed.

Therefore, the response to Recommendation A16-09 remains as Satisfactory Intent.

Transport Canada’s response to Recommendation A16-09 (March 2019)

TC agrees with the Board’s recommendation.

To address this recommendation, Transport Canada released AC4O1-004 Conduct of Instrument Proficiency Checks https:ww.tc.gc.ca/en/services/aviation/reference-centre/advisory-circulars/ac-401-004.html, effective November 1, 2015. Specifically, the document describes how instrument rated pilots can demonstrate compliance with currency requirements of an instrument rating.

To further address this recommendation, TC needs additional time to make regulatory changes to the CARs that would require a recency demonstration within the first 12 months following the completion of an Instrument Flight Check.

TSB reassessment of Transport Canada’s response to Recommendation A16-09 (May 2019)

In its latest response, Transport Canada (TC) indicated that it has issued Advisory Circular (AC) 401-004 Conduct of Instrument Proficiency Checks, which became effective on 1 November 2015, and describes how instrument-rated pilots can demonstrate compliance with currency requirements of an instrument rating.

The purpose of AC 401-004 is to set out “…the reference documents, techniques, procedures and the marking criteria to be used…for the conduct of an Instrument Proficiency Check (IPC).” An IPC must be completed within the 24 months preceding an instrument flight rules flight. The AC highlights that it may be desirable to seek recurrent instrument training prior to conducting the IPC; however, the AC is “provided for information and guidance purposes” and “…does not establish minimum standards.”

In addition, TC indicated that additional time is required to implement regulatory amendments to the Canadian Aviation Regulations, and that work in that regard has yet to start. TC anticipates that this matter will be considered as part of its fall 2019 regulatory prioritization process.

As such, until TC provides additional details on its proposed regulatory amendments, including timelines, it is not possible for the Board to determine to what extent these actions will address the safety deficiency identified in Recommendation A16-09.  

Therefore, the response to Recommendation A16-09 remains as Satisfactory Intent.

Next TSB action

The TSB will continue to monitor the progress of TC’s actions to mitigate the risks associated with the safety deficiency identified in Recommendation A16-09, and will reassess the deficiency on an annual basis or when otherwise warranted.

This deficiency file is Active.

 

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